1. Hydrocephalus
dr. I Made Bayu Wisnu Wardhana
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
2. Basic definition
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• An abnormal accumulation of cerebrospinal fluid within the ventricles of
the brain.
3. Epidemiology
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• Estim ated prevalence: 1–1.5%. Incidence of congenital hydrocephalus is
≈ 0.9–1.8/1000 births (reported range from 0.2 to 3.5/ 1000 births)
4. Etiologies of hydrocephalus
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• General information
• Hydrocephalus (HCP) is either due to subnormal CSF reabsorption or, rarely, CSF
overproduction.
• ● subnormal CSF reabsorption. Two main functional subdivisions:
• 1. obstructive hydrocephalus (AKA non-com m unicating): block proximal to the arachnoid
granulations (AG) OnCTor MRI: enlargem ent of ventricles proxim al to block (e.g.
obstruction of aqueduct of Sylvius →lateral and 3rd ventricular enlargem ent out of
proportion to the 4th ventricle, sometimes referred to as triventricular hydrocephalus)
• 2. communicating hydrocephalus (AKA non-obstructive): defect in CSF reabsorption by the
AG
• ● CSF overproduction: rare. As with some choroid plexus papillom as; even here,
reabsorption is probably defective in some as normal individuals could probably tolerate
the slightly elevated CSF production rate of these tumors
5. Specific etiologies of hydrocephalus
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• 1. congenital
• a) Chiari Type 2 m alform ation and/or myelom eningocele (MM)
(usually occur together)
• b) Chiari Type 1 m alform ation: HCP m ay occur w ith 4th ventricle
outlet obstruction
• c) prim ary aqueductal stenosis (usually presents in infancy, rarely in
adulthood)
• d) secondary aqueductal gliosis: due to intrauterine infection or germ
inal m atrix hem orrhage3
• e) Dandy Walker m alform ation (p.256): atresia of foram ina of Luschka
& Magendie. The incidence of this in patients w ith HCP is 2.4%
• f) X-linked inherited disorder (p.401): rare
6. Specific etiologies of hydrocephalus
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• 2. acquired
• a) infectious (the m ost com m on cause of com municating HCP) ● post-m eningitis; especially purulent
and basal, including TB, cryptococcus (p.376) ● cysticercosis
• b) post-hem orrhagic (2nd m ost com mon cause of com m unicating HCP) ● post-SAH ● post-
intraventricular hem orrhage (IVH): m any w ill develop transient HCP. 20–50% of patients w ith large
IVH develop perm anent HCP requiring a shunt
8. Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Management Priority
• Simple clinical assessments and interventions are
paramount in austere and operational environments.
• Creative solutions involve improvisation of materials to
address life-threatening physiology.
• E.g, an initial airway intervention might stop at side
positioning and placing an oral airway in an unconscious
patient when endotracheal tubes and the resources to
manage the casualty after intubation are not available.
10. Comunication
• Communication is the dominant challenge in disaster response across all
environments.
• Application of the National Incident Management System’s - Incident
Command System (ICS) can improve response and communication.
Communication plans should be rehearsed regularly with disaster
exercises. Good communication will also provide valuable information
about outside events, available plans, and resources, thus reducing fear
and rumors.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Challange
11. Transportasi : any vehicle can be used to move casualties, including buses,
cars, and boats.
Safety and security: are challenged due to environmental and conflict
conditions. These conditions should be emphasized, planned for, and
practiced in drills. Protection of the facility is a key function of the
operations chief in ICS.
Mass volunteerism and self-deployment can swamp a facility or scene
with well-meaning providers who have undetermined credentialing and
skills. They must be managed by a plan that controls access until they are
acceptably vetted. Joining medical assistance teams in advance of events
prevents this difficulty.
Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Challange
12. • ATLS in the Operational Environment (ATLS-OE) : ATLS in the Operational Environment
(ATLS-OE) is a course of instruction that emphasizes the importance of maintaining
situational awareness while providing care in a potentially hostile, resource-constrained,
and manpowerlimited environment.
Departemen Bedah RSMH/FK Unsri
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Military Trauma Care
13. • Implementation of ATLS-OE
ATLS-OE is currently offered for all new military medical officer accessions, through
the Defense Medical Readiness Training Institute and the Uniformed Service
University, and will soon be made available to all military ATLS programs.
• Improving Survival from Active Shooter: Critical events in an integrated response
to an active shooter event are represented by the acronym THREAT:
Threat suppression
Hemorrhage control
Rapid Extrication
Assessment by medical providers
Transport to definitive care
Departemen Bedah RSMH/FK Unsri
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Military Trauma Care
16. Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Refference:
Henry, S. (2018). ATLS 10th edition offers new insights into managing
trauma patients. Bulletin of the American College of Surgeons.
