Management of acute hydrocephalus

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  • Endoscopic view of the Foramen of Monro. The arrow is on the fornix and pointing to the Foramen of Monro. The arrowhead points to the choroid plexus in the lateral ventricle entering the foramen.Endoscopic view of the floor of the third ventricle. The structures seen are the basilar artery bifurcation (arrow) immediately anterior to the mamillary bodies. The third ventriculostomy stoma is made anterior to the basilar artery. The arrowhead points to the infundibulum at the base of the pituitary stalk.
  • Endoscopic view of the Foramen of Monro. The arrow is on the fornix and pointing to the Foramen of Monro. The arrowhead points to the choroid plexus in the lateral ventricle entering the foramen.Endoscopic view of the floor of the third ventricle. The structures seen are the basilar artery bifurcation (arrow) immediately anterior to the mamillary bodies. The third ventriculostomy stoma is made anterior to the basilar artery. The arrowhead points to the infundibulum at the base of the pituitary stalk.
  • Endoscopic view of the Foramen of Monro. The arrow is on the fornix and pointing to the Foramen of Monro. The arrowhead points to the choroid plexus in the lateral ventricle entering the foramen.Endoscopic view of the floor of the third ventricle. The structures seen are the basilar artery bifurcation (arrow) immediately anterior to the mamillary bodies. The third ventriculostomy stoma is made anterior to the basilar artery. The arrowhead points to the infundibulum at the base of the pituitary stalk.
  • (A) Axial T-1 weighted magnetic resonance image with contrast showing the nonspecific enhancing on the basalcisterns (arrow) and enlarged ventricles. (B) Neuroendoscopic view of the basal cisterns while taking a biopsy of the exudates and arachnoid adhesions.
  • moremarked symptoms and a longer history earlier
  • moremarked symptoms and a longer history earlier
  • Management of acute hydrocephalus

    1. 1. EMERGENCIES IN NEUROSURGERY MANAGEMENT OF ACUTE HYDROCEPHALUS 29-9-2012 Dewan Auditorium, HTAA
    2. 2. Medical Management of Hydrocephalus • Diuretics (frusemide and acetazolamide) and steroids are known to decrease CSF production. • Maintaining PaCO2
    3. 3. Surgical Management of Hydrocephalus • 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.
    4. 4. 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.
    5. 5. Surgical Management of Hydrocephalus • 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)
    6. 6. Surgical Management of Hydrocephalus • 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
    7. 7. • 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
    8. 8. 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
    9. 9. Hemorrhage (the most severe being due to basilar rupture) Injury of neural structures . In the immediate postoperative period Hematomas, infections, an d cerebrospinal fluid leaks
    10. 10. Utility of point of obstruction model
    11. 11. Basal Meningitis and Hydrocephalus 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
    12. 12. Basal Meningitis and Hydrocephalus Transventricular Neuroendoscopic Exploration and Biopsy of the Basal Cisterns
    13. 13. Hydrocephalus in TB Meningitis MEDICAL MANAGEMENT The 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, Repeat the cranial CT after three weeks of treatment, or earlier if there is a clinical indication. Has been reported to be successful in approximately 75% to 80% of patients
    14. 14. 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 depressed level of consciousness, temporary external ventricular drainage Endoscopy TV Receives a VPS. who do not respond to medical therapy or who have NCHC.
    15. 15. Hydrocephalus in TB Meningitis SURGICAL MANAGEMENT Endoscopy TV first described in 2003 as an alternative to VPS insertion in patients with NCHC The clinical outcome of the hydrocephalus in a nonselective approach to ETV was reported as “satisfactory” in 50% and “acceptable” in 18% If the ETV cannot be completed technically, Perform lumbar punctures for a few days after the ETV VPS.
    16. 16. Shunt Malfunction presence of an obstructive hydrocephalus at the time of Frequently located at the level of the aqueduct, shunt malfunction 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.
    17. 17. Shunt Malfunction 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; Endoscopy TV
    18. 18. 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
    19. 19. 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
    20. 20. 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
    21. 21. TREATMENT OF HEMATOCEPHALUS If ventricular clots are secondary to aneurysm rupture or arteriovenous malformations Fisher 4 subarachnoid hemorrhage with massive tetraventricular clots Perform early surgery or coiling to secure the aneurysm or malformation in patients who are intubated and have a Glasgow Coma Scale score 6 (motor response 4–5) decrease intracranial hypertension by endoscopically cleansing clots Early endoscopic aspiration in patients
    22. 22. NORMAL PRESSURE HYDROCEPHALUS NPH who improve clearly after one or several CSF lumbar punctures. proceed with shunting More marked symptoms and a longer history earlier Extensive counselling with the patients’ relatives should be performed to weigh the expected benefits from shunting and the possibilities of long-term shunt dysfunction Patients at an early clinical stage with mild gait disturbance may be monitored initially, repeated CSF removal via lumbar puncture disease should progress proceed with shunting
    23. 23. Acute Obstructive Hydrocephalus Caused by Cerebellar Infarction 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 Ventriculostomy and external ventricular drainage 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. If external ventricular drainage is effective and consciousness is restored, Repeat CT scan in 48-72 hours will perhaps confirm a decrease in mass effect and stabilization or reduction of ventriculomegaly 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.
    24. 24. Correction of Congenital Hydrocephalus in Utero In utero decompression of obstructive hydrocephalus improves overall survival Improves gross ventriculomegaly,
    25. 25. Thank You

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