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SEMINAR

“MANAGEMENT OF THE
HYDROCEPHALUS AND OUTCOME”

PRESENTED BY : DR. SURAJ JAIN

MODERATOR : PROF. Dr. V.K. RAINA


INTRODUCTION
Hydrocephalus is common neurological
problem. Attention to different hydrocephalic
conditions come in light mainly by innovative
development in imaging and operative
methods. The strategy of treating
hydrocephalus has changed, especially because
of scientific approach to CSF circulation, by
possibility of measuring CSF flow resistance
and by MRI based flow studies of the CSF
circulation. Treatment of hydrocephalus have
changed from shunting which give rise to many
complication and re operations to minimally
invasive endoscopic procedures.
Definition - hydrocephalus is defined as pathological increase in
intracranial CSF volume with increased intracranial pressure (ICP).
CSF Dynamic
Secretion
-Most CSF (70%)
secreted in choroids
plexus within ventricle
-Extra choroid CSF
production occur in
subarachnoid space
-Transapendymally

Absorption
-Mainly in arachnoid
villi in superior sagital
sinus
-Also occur in leptomeningis
-Ventricular system
-Lymphatics
SIGNS AND SYMPTOMS
1) IN INFANTS
• rapid skull growth
• macrocrania
• bulging fontanelle
• splitting of cranial sutures
• shiny skin with distended scalp vein
• sunset appearance
• opthalmoplegia
• papilloedema
• frontal bossing
• transcranial illumination
2. IN CHILDREN
•headache
•vomiting
•alteration of consciousness
•double vision
•behavioral change
•memory loss
•papilloedema
•convulsions
3. IN ADULTS
•progressive headache
•vomiting
•progressive dementia
•epileptic fits
•urinary incontinence
•limb weakness
•papilloedema
INVESTIGATION
Goal of investigations:

1) To confirm diagnosis
2) Differentiating between communicating
and non communicating
3) To know site of obstruction
4) To know anatomical detail
5) For follow up
1. CSF EXAMINATION
2. HEAD CIRCUMFERENCE
3. FUNDUS EXAMINATION
4. RADIOLOGICAL INVESTIGATIONS
A. X RAY SKULL
•widening of sutures
•silver beaten appearance
•enlargement of pituitary fossa with erosion if dorsal sella
•shallow posterior fossa
B. ULTRASONOGRAPHY
•atrial size is the most useful measurement of ventricular size
•normal size in newborn is 7.6mm. more than 10mm indicates
ventriculomegaly
•Ventriculohemispheral ratio more than 35% indicates
ventriculomegaly
•Hanging choroid sign, nomally less than 25% more than 75 %
indicates ventriculomegaly
Advantages of USG are
• no exposure to radiation
• can be performed bedside
• axial, sagittal, coronal image can be obtained
• can demonstrate lateral & 3rd ventricular
morphology, interventricular mass and
periventricular leukomalakia
Disadvantages of USG are
• operator dependant
• not reproducible
• cant demonstrate the exact site and cause of
obstruction
• cant evaluate 4th ventricle and sub arachnoid space
pathology
CT SCAN
Advantages of CT Scan are as follows
• can be performed quickly
• greater anatomical detail
• preferential dilatation of occipital horn may be seen
• can distinguish between communicating and non
communicating varieties
Disadvantages of CT Scan are as follows
• provides only axial image
• exposure to radiation
• inferior to MRI for visualization of brain
stem/posterior
fossa
MAGNETIC RESONANCE IMAGING
Advantages are as follows
• provide greatest amount of anatomic detail
• provide clues in etiology
• differentiate between subdural effusion & enlarge sub
arachnoidal spaces
• visualization of posterior fossa and brain stem
• Cine MRI is useful to identify site of obstruction
• no radiation exposure
RADIOGRAPHIC FEATURES
• concomitant & proportional dilatation of temporal horn
• enlargement of anterior & posterior recess of 3rd ventricle
• shortening of mammilopontine distance
• narrow ventricular angle
• widening of radius of frontal horn
• cortical effacement
• attenuation of flow voids in 3rd ventricle, aqueduct of sylvius,
4th ventricle & transependymal oedema
MANAGEMENT
Treat Cause of hydrocephalus:
Medical Management :

1. Mannintol :
2. Hyperventilation :
3. Loop diuretics :
4. Steroid :
5. Acetazolamide :
6. Barbiturate coma :
SURGICAL TREATMENT :
Goal of surgery:
To decrease ICP
To maximize the patient’s neurological
outcome and cognitive function
To maximize the size of cortical mantle
while minimally complication
LP and Ventricular tap:
These are the simple and quick methods
VP SHUNT
Indication:
In newborn and children:
In patient without a treatable cause of hydrocephalus
Idiopathic hydrocephalus
Failed III ventriculostomy
Communicating / obstructive hydrocephalus
Myelodysplactic children with healing wound under tension
Sing and symptom of brain stem compression develop in presence of ventriculomegaly
Indication of shunt operation in adult:
Symptoms and signs of elevation of ICP in high pressure hydrocephalus
Progressive signs of brain herniation
Progressive dementia gait and urinary disturbance : Other indication in which endo III ventricular can
be applied
Multiple operated hydrocephalus
Arachnoid and porencephalic cyst
Spontaneous/ iatrogenic CSF leakage
Temporary neutralization of elevated ICP
Contraindication :
Absolute :
Infection specific ventriculitis
Intraventricular hemorrhage
Relative :
Arresteo or atropic hydrocephalus
Hydran encephaly
COMPLICATIONS
Common Uncommon

Cranial Subcutaneous Peritoneal

Infection Subdural Shunt irrigation Peritonitis


hygromas
Obstruction Subdural Shunt Pseudocyst
hematoma disconnection Perforation
Hemiparesis Shunt fracture hernias
Hematoma

Over
drainage
1) Infection : 5-10% Risk of shunt infection is :
Organism:
Gram positive staphylococcus epidermis 40% cases, staphy aureuns 20%, propionbacterium,
streptococcus corneobacteria
Gram negative organism 15%, pseudomonas enterobacterium
Multiple strain in 20% shunt infection
Sign and symptoms:
Shunt failure
Meningismus
Headache
Nausea / vomiting
Irritability
Fever, lethargy acute abdomen
Investigations:
CBC
Blood culture
Urine culture
Radiographic shunt scan
USG abdomen/ CT scan abdomen
CSF tap
Treatments:
IV antibiotics – broad spectrum, IV vancomycin + rifampicin
IV cetraxone + gentamycin
Intrathecal aminoglycoside
-Cure rate of the shunt infection in situ with intravenous antibiotic along have reported in the
range of 30%.
-Removal of the shunt.
Mechanical failure:
Occur in the 17% all shunt cases.
Is most common complication of shunt.
Proximal occlusion is most common
Shunt catheter can be occluded from variety of cause such as :
Debris/ blood/ protein
Intraparenchymal placement
Choroid plexus
Coaptation of ventricular wall
Gliosis
Infection
Catheter breakage of discontinuity is second most common cause
of the shunt failure.
Shunt obstruction occur more than a year after insertion usually
because choroids plexus had occluded the ventricular catheter.
Symptom:
Headache
Nausea/ vomiting
Drowsiness
Irritability
Six nerve palsy
Behaviour disturbance
Subcutaneous fluid collection
Diagnosis :
Pumping the shunt
X-ray head, chest and abdomen
CT scan
Shunt tap
Treatment :
Replace either malfunction component or entire system.
Over drainage:
When patient is sitting or standing the differential hydrostatic pressure
of shunt system is proportional to alpha height of vertical column of
CSF in peritoneal tube distal to the valve.
This pressure lead to gravitational induced siphoning and negative ICP.
Symptom:
Postural headache
Nausea
Lassitude
Diplopia
Elevated ICP syndrome
Slit ventricular syndrome
Occlusion of aquaduct of sylvius
Subdural haematoma
Orthostatic hypotension
Treatment:
Upgrading the valve to a higher pressure
By placing an antisiphan device
By performing an endoscopic IIIrd ventriculostomy
Lumbar Peritoneal Shunt
Indications:
Communicating hydrocephalus with or without small
or collapsed ventricular system
Advantages:
Extracranial course
Avoid complication of IIIrd ventriculostomy
Contraindication:
Obstructive hydrocephalus
Complication:
Overdrainage (spinal headache)- most common)
Transient root symptom and sign
Scoliosis / hyper lordosis / kyphoscoliosis – rare
Endoscopic IIIrd Ventriculostomy
Criteria:
Candidate should have obstructive hydrocephalus
Candidate should have dilated IIIrd ventricle which arbitary
define as > 1 cm in by coronal plane
Floor of the 3rd ventricle should be suitable for fenestration i.e.,
attenuated or balging downward into inter pendicular cistern.
Area of attenuation should be atleast 5 mm in diameter and
should be in front of basilar artery.
Indication:
Posterior fossa tumor
Late onset (over 24 yrs of age) aqueduct block such as tectal
tumor
New born with myelomeningocele and associated blockage either
at aqueductal or exists of the 4th ventrical.
In the patient with the repeated shunt failure
Contraindication:
Chronic meningitis
Sub dural haemorrhage / intra ventricular
haemorrhage
Complications:
Infection rate 2-15%
Bleeding for the basilar artery or its branches
Hemiparesis, owing to damage to pedicle or its
perforating arteries
Hypothalmic damage due to the proximity to
third ventricle
Endoscopic Choroid Plexus Coagulation:
Indication:
Infant with slowly progressive communicating hydrocephalus
Success rate is 64% at 10 yrs follow up
Hydrocephalus as a result of CSF over production eg. Choroids plexus
papilloma and hyperplasia
Communicating hydrocephalus where shunt insertion is not feasible
Intractable shunt failure
Contraindications:
Obstructive hydrocephalus
Rapidly progressive communicating hydrocephalus with acutely raised ICP
Complications:
Mortality
In 1 series on 125 patients mortality is 1.
Post operative fit 1.9%
Severe low pressure state (0.8%)
Infection 0.5%
Overall 35% patient remained shunt independent after 10 year follow up
CONCLUSION
In new millennium shunt placement and
revision are low risk. Operation but long term risk of
infection obstruction and antecedent neurological
morbidity is quite high as no shunt system is ideal.
The rapid development in the technology and
enormous amount of clinically experience with CSF
shunting point to next generation of shunts which
could be ventriculosinus (superior sagital sinus) shunt
or computerized electronic shunt, till that shunting
should be avoid whenever possible and endoscopic III
ventriculostomy should be attempted in appropriated
selected patient, CSF diversion have lead to decrease
mortality and have improved overall outcome in the
patient with hydrocephalus.