Seminar Hydrocephalus Surgery Yr 4 Rotation 3

7/22/2019 Seminar Hydrocephalus Surgery Yr 4 Rotation 3

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Management of HydrocephNeurosurgery Rotation 3

UiTM MBBS Year 4 (2013/2014)13thDecember 2013

1- MUHAMMAD KYIDIR BIN MOHD IDROS

2- NAZURAH NADIA BT. AZIMUDDIN

3- MUHAMAD ASRI B. ABD RAHMAN

4- MOHD RIDZUAN BIN HAMID

5- MOHAMMAD FIKRI B. ROSLI


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ANATOMY OF VENTRICULARSYSTEM2 Lateral Ventricles

Largest cavity

Occupies large area of cerebral

hemisphere Opens through interventricular

foramen into the 3rdventricle

3rdVentricle

Slit-like cavity between the two

thalami (each side)

Continues posteroinferiorly with

Aqueduct of Sylvius

4thVentricle

Pyramidal in shape

Posterior to the pons and medulla

Extends inferoposteriorly

Inferiorlynarrow central canal in

spinal cord

FlowsForamen of Luschka and

Foramen of Magendie


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CSF PRODUCTIONAND FLOW


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Physiology of CSF Formation

Secreted by choroid plexus of:

Inferior horn of each lateral ventricle

Posterior portion of 3rdventricle

Roof of 4thventricle

Humans total volume of CSF is about 120-150 mL and the rate of CSF production

about 0.5 mL/min (400-500 ml/day) and the CSF turnover time of about 5 hours.

It has been estimated that 50-70% of the CSF is formed in the choroid plexuses an

the remainder is formed around blood vessels and along ventricular walls.


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CSF FLOW2 Lateral ventricles

2 Foramen of monro

3rdventricle

Aqueduct of Sylvius

4thventricle

2 lateral foramina of Luschka

1 midline foramen of Magendie

Subarachnoid space

With the aids of

ciliatedependymal cell,

arterial

pulsation of

choroid plexus


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Subarachnoid space

2 ways:

Superiorly-inferior surface of cerebrum andlater to lateral aspect of cerebral hemisphere

Inferiorly-spinal cord and cauda equinabefore rises superiorly

Arachnoid granulation

(villi)

Venous system(Superior sagittal sinus)

CSF ABSORPTIONWith th

cerebra

puls

Pas

dep


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CSF PRESSURE The pressure is kept remarkably constant

In lateral recumbent positionPressure measured by spinal tap/lumbar puncture is

~60-150 mm water

Pressure may be raised by straining, coughing andcompressing internal jugular vein (raised ICP;one-pressureway causing no csf reabsorption, hence increases csf

pressure) Production of CSF is not pressure regulated

Continues to be produced even if reabsorption mechanism isobstructed


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Normal constituents of CSF


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PHYSICAL CHARACTERISTICS OCSF

CharacteristicsAppearance Clear and colorless

Total Volume 150 ml

Rate of production ~0.5 ml/minute (~500ml/day)

Composition

Protein

Glucose

Chloride

0.15-0.45 g/l

0.5-0.85 g/l (50% blood glucose)

7.2-7.5 g/l

Number of cells 0-3 lymphocytes


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Bacterial Meningitis

Appearance - Cloudy & Turbid

White Cells - Raised neutrophils

Red Cells - Absent

Protein - High or Very HighGlucose - Very Low

Viral Meningitis

Appearance - Normal

White Cells - Raised lymphocytes

Red Cells - Absent

Protein - Normal or HighGlucose - Normal or Low

Tuberculous Meningitis

Appearance - Normal or Slightly CloudyWhite Cells - Raised lymphocytes

Red Cells - Absent

Protein - High or Very High

Glucose - Very Low


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Guillan-Barr Syndrome

Appearance - Normal

White Cells - Normal

Red Cells - Absent

Protein - HighGlucose - Normal or Low

Multiple Sclerosis

Appearance - NormalWhite Cells - Raised lymphocytes

Red Cells - Absent

Protein - High

Glucose - Normal

Subarachnoid Hemorrhage

Appearance - Usually blood stained

White Cells - Normal

Red CellsPresent (Very High)

Protein - Normal or HighGlucose - Normal or Low


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FUNCTIONS OF CSF

1. Cushions - protects CNS from mechanical trauma

2. Bouyancy

3. Reservoir and assists in the regulation of the contents of the skull - inbrain volume/blood volume will increase CSF volume

4. CNS nourishment

5. Removal of metabolites from CNS


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HYDROCEPHALUS

NAZURAH NADIA


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Definition

increased volume of cerebrospinal fluid (CSFwithin the skull, most frequently in theventricles.

Textbook of Clinical Neurology,


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The accumulation of excessive CSF within thventricular system may d/t:

1. Impaired flow (obstructive/non-communicating)

2. Impaired resorption (communicating)

3. Overproduction (communicating)

increase ICP


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Classification

1. Non-communicating Hydrocephalus(Obstructive)

2. Communicating Hydrocephalus (Non-

obstructive)


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1. Non Communicating Hydrocephalus Obstructive hydrocephalus

CSF flow obstruction in the ventricular system


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Ventricular System


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Aqueductal stenosis

Abscess

Chiari malformation

Dandy-Walker malformation

Hematoma

Infectious

Klippel-Feil syndrome

Mass lesions

Tumors & neurocutaneous disorders

Vein of Galen malformation

Walker-Warburg syndrome

X-linkedClinical pediatric neurology : A sign & symptoms approach, Gerald M.


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2. Communicating Hydrocephalus Non-obstructive hydrocephalus

Impaired CSF resorption: Sub ArachnoidHemorrhage(SAH)

Functional impairment of the arachnoidgranulations (congenital)


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Causes

Infants & children

Congenital

Acquired

Adults

Acquired


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Examples-CongenitalDANDY WALKER MALFORMATION


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Clinical features


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Effects (clinical features)

The clinical features depend on:

Age

Cause

Location of obstruction

Duration

Rapidity of onset

Setti S.Rengachary, Richard G. Ellenbogen. Principles Of

Neurosurgery.Second Edition.2005.Elsevier Mosby


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Infants

Irritability

Vomiting

Drowsiness

Macrocephaly

Distended scalp veins

Frontal bossingpositive Macewenssignpoor head controllateral rectus palsysetting-sun sign




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Acute (high-pressure) hydrocephalu

oHigh ICP:

Headache

Nausea

Vomiting

Papilloedema

oAbducens palsy & truncal ataxia, may, incorrectly, suggest a fossa lesion (false localizing sign)

oEpisodic visual obscurations graying- dangerous pressure w



Chronic or normal pressure hyrocep


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Chronic or normal pressure hyrocep(NPH)Clinical triad of NPH:

Gait disturbance- magnetic, apraxic

Urinary incontinence- uninhibited neurogenic bladder

Dementia

Setti S.Rengachary, Richard G. Ellenbogen.

Principles Of Neurosurgery.Second

Edition.2005.Elsevier Mosby


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Papilloedema 6thnerve palsy


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Imaging studies forhydrocephalus

-MOHD RIDZUAN BIN HAMID-


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Imaging modalities

Skull ultrasound

Skull radiograph (x-ray)

CT Scan

MRI

Skull ultrasound


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Skull ultrasound

Uses high frequency sound wave

Method of choice to diagnose intra-

uterine cases

First investigatory method forinfantile cases(6months-2y/o)

- open anterior fontanelle, simpleprocedure, non-invasive

Internal cranial structure (ventricles,parenchyma,vessels) are visualizedin coronal and saggital planes


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Ventricular


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Ventricular-hemisphericratio

Level of Foramen ofMonroe in coronal section

Distance of the lateral wallof lateral ventricle from

midline to the hemisphericwidth

If > 0.35, suggestive ofhydrocephalus


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Skull radiograph

Simple, inexpensive and non invasive imaging method with

diagnostic value Used in older children

anterior fontanelle closed

ultrasound cannot penetrate bony structure

Can detect several diagnostic signs

Enlarged craniumWide spread / split sutures

Disproportionate craniofacial ratio

J-shaped sella

silver beaten appearance of calvarium

Enlarged cranium


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Enlarged cranium


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Compressed cerebral sulci


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Compressed cerebral sulci

Enlarged fron

Enlarged 3rdventricle

Enlarged temporal horn

MRI


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MRI

Can project the brain in axial,coronal,and saggital pro

provide better anatomical detail of lesions causinghydrocephalus and is particularly useful in the diagno

aqueduct stenosis

Can detect transependymal resorption and low grade

more clearly than CT-scan Can detertmine CSF flow across aqueduct


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NormalDilatation of Ventricles


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Dandy Walker


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Dandy WalkerSyndrome

Everted hypoplasticvermis (long arrow)

Large posterior fossacyst (short arrow)

Hypoplasia of thebrainstem andcerebellum (b)

MRI/CT Criteria


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MRI/CT Criteria

Acute Hydrocephalus

Size of both temporal horns (>2mm)/clearly visible (normally-barely visible)

Evans ratio >30%. (Evans ratio-ratio ofthe largest width of the frontal hornsto maximal biparietal diameter.

Ballooning of frontal horns of lateralventricles and third ventricle-mightindicate aqueductal obstruction.

Upward bowing of corpus callosum onsaggital MRI.

Chronic Hydroceph

Temporal horns may bprominent compared thydrocephalus.

Third ventricle may hesella turcica

Sella turcica may be er Macrocrania (ie, occipitofronta

>98thpercentile) may be present.

Corpus callosum maybatrophied


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Management ofHydrocephalusMohammad Fikri Bin Rosli

Management of Hydrocephalus


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Management of Hydrocephalus

Acute hydrocephalus: emergency as condition mayprogress over minutes or hours to coma and death.

Management

Medical Surgical

Medical management


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Medical management To delay surgical intervention

Not effective in long term treatment of chronic hydrocephalus

Acetazolamidecarbonicanhydrase inhibitors

Furosemideloop diuretics

Reduce CSFproduction

IsosorbideIncrease CSFreabsorption

S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2

Surgical management


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g g

1) External ventricular drainage (EVD)

Temporary measure to relieve hydrocephalus

Catheter are inserted to the right of midline, anterior tocoronal sutures to enable the tip of catheter rest adjacent tthe foramen of monro in lateral ventricle

Catheter connected to a drain set which the CSF will drainswhen the ventricular pressure exceeded 20mmHg

Bailey & Loves Short Practice of Surgery 26t


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Ventriculoatrial shuntVentriculoperitoneal

shunt

Ventriculopleural

shunt

Consist of 3 components:

Proximal ventricular catheter


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Proximal ventricular catheter

One way valve: permits CSF flows out of ventricular

Opening pressure of the valve can be high, medium or low

High pressure may cause inadequate drainage of CSF

Low pressure may cause over-drainage of CSF

Distal catheter: allow the fluid to flows into the reservoir, allow CSF to beaspirated



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Shunt blockagedue to cellular and proteinaceous debris, choroid plexus adhesion

Low pressure syndromedue to over-drainage of CSF which consist of headache wstanding, neck pain, and nausea

Subdural hematoma or subdural hygromadue to collapsed ventricles causing accufluid in subdural space

S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2

3) Endoscopic third ventriculostomy


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Useful in obstructive hydrocephalus due to aqueduct stenosis

Neuroendoscopeinserted into frontal horn of lateral ventricle and theninto third ventricle via foramen of monro

Complication

Reblockage

Damage to basillar artery

Damage to the fornix



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Other type of


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Other type ofhydrocephalus

Hydrocephalus ex vacuo

Normal pressure hydrocephalus

TBM and hydrocephalus

Hydrocephalus Ex Vacuo


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Occur in the presence of brain damage due to stroke, injury or actualshrinkage of brain substance

Brain are atrophied and wasted

Features are:

Increased production of CSF

Cerebral atrophy

Dilatation of the ventricles

ICP usually is normal. HOWEVER

Causes: Alzheimer disease, Multiple sclerosis, Multiple strokes, Huntingtdisease, Leukodystrophies.

http://www.medicinenet.com/hydrocephalus/page
http://www.medicinenet.com/hydrocephalus/page2.htmhttp://www.medicinenet.com/hydrocephalus/page2.htm


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Mild to moderate cortical atrophy.

Large ventricles, particularly the

third ventricle and inferior horns of

the lateral ventricles.


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Triad of clinical features: Gait disturbance, urinary incontinence andcognitive decline (dementia)


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cognitive decline (dementia)

Opening pressure on LPtypically normal

Lumbar infusion testing can also be done to measure CSF pressure.

Imagingusually reveals ventriculomegaly Treatment

Ventriculoperitoneal shunt

http://emedicine.medscape.com/article/1150924-

Bailey & Loves Short Practice of Surgery 26thEditio
http://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overview


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Hydrocephalus is common sequelae of TBM

CT scan intense meningeal enhancement


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CT scanintense meningeal enhancement

Management:

Medical therapy: steroids eg: prednisolone and anti-tuberculosis drug. Surgery: Ventriculoperitoneal shunt

Rich Foci

http://emedicine.medscape.com/article/1166190-

References
http://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overview


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Bailey & Loves Short Practice of Surgery 26thEdition

S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2ndEdition

http://emedicine.medscape.com/article/1166190-overview

http://emedicine.medscape.com/article/1150924-overview
http://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overview


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Seminar Hydrocephalus Surgery Yr 4 Rotation 3

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