Management of acute hydrocephalus

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MANAGEMENT OF ACUTE HYDROCEPHALUS 29-9-2012 Dewan Auditorium, HTAA EMERGENCIES IN NEUROSURGERY Symposium 7: Hydrocephalus

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Neurosurgery

Transcript of Management of acute hydrocephalus

Page 1: Management of acute 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

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Medical Management of Hydrocephalus

• Diuretics (frusemide and acetazolamide) and steroids are known to decrease CSF production.

• Maintaining PaCO2

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• 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

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• 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

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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

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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

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• 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

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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

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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

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Utility of point of obstruction model

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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

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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

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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.

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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

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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.

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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.

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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;

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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

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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

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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

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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

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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

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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.

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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

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Thank You