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Dr PIOCHE Pierre-Antoine
NeuroRéanima7on 🧠
papioche@chu-clermon=errand.fr
28 octobre 2020
LE DILEMME DE L’HYDROCÉPHALIE CHEZ
LES PATIENTS PRÉSENTANT UN
DÉSORDRE DE CONSCIENCE
&
INTRODUCTION
DEFINITIONS
TRAITEMENTS
DISCUSSION
Désordre de conscience et hydrocéphalie
Hydrocéphalie, defini5on Clinique, Radiologique et Test Diagnos5que
Cranioplastie, derivation et outcome post hydrocéphalie
2
INTRODUCTION Désordre de Conscience
3
Syndromes cliniques DoC
Etats végéta7fs (UWS)
Etats de conscience minimaux (CMS /MCS)
DOC et HYDROCEPHALIE
7
Ischémie HSA HIP / Trauma crânien
Trouble de réabsorp7on du LCR
DOC après TC ou HSA 50% découverts en rééduca7on
20%
DEFINITION DE L’HYDROCEPHALIE
7
Aiguë Subaiguë Chronique
H J M
Hydrocéphalie (HydroC) et DOC
Limite la récupéra7on
Atrophie cérébrale progressive
INTRODUCTION Hydrocéphalie et DOC
3
Ventriculomégalie
LA VENTRICULOMEGALIE EST-ELLE UNIQUEMENT SECONDAIRE A L’ATROPHIE OU A UNE HYDROCEPHALIE ?
SUSPECTER UNE HYDROCEPHALIE
7
Clinique de l’HydroC
Céphalées
Troubles de l’éveil
Déclin cogni7f
Incon7nence
Troubles de la marche
CRS-R
Fonc%on Audi%ve
Fonc%on Visuelle
Fonc%on motrice
Bi-mensuelle
Clinique
SUSPECTER UNE HYDROCEPHALIE
7
NeuroImagerie
Angle Calleux
< 80°
Indice d’Evans
> 0,3
SUSPECTER UNE HYDROCEPHALIE
7
NeuroImagerie
Œdème péri-épendymaire Elargissment V. Sylvienne Vide de flux V4 - Aqueduc
SUSPECTER UNE HYDROCEPHALIE
7
NeuroImagerie
Arterial Spin Labelling
SB Périventriculaire
Ganglions de la base
Thalamus
Diminu8on de la perfusion
J. Virhammar et al. American Journal of Neuroradiology, 2017
SUSPECTER UNE HYDROCEPHALIE
7
NeuroImagerie
MR Elastrogaphy
N. Fattahi et al. American Journal of Neuroradiology, 2016
Majoration de la rigidité tissulaire
HYDROCEPHALIE – TEST DIAGNOSTIQUE
7
Ponction lombaire unique
Retrait de 40 à 50 mL
Test de ponc8on lombaire unique
Sensibilité variable 20-60%
Améliora7on des symptômes moteurs
Peu ou pas d’effet cognitifs
Williams, M.A. and al. Neurology 2013
→ Valeur prédic7ve limitée
→ Pas d’évaluation chez le DoC
TESTS DIAGNOSTIQUES
7
Drainage lombaire externe
Walchenbach et al. J Neurol Neurosur 2002
Drainage pendant 72h
Sensibilité = 50 à 100%
VPP = 80-100%
→ Durée de drainage inconnue pour
améliorer l’éveil
→ Faux-négatifs +++
TESTS DIAGNOSTIQUES
7
Test d’infusion lombaire
Eklund A et al. Med Biol Eng Comput 2007
TESTS DIAGNOSTIQUES
7
Test d’infusion lombaire
Eklund A et al. Med Biol Eng Comput 2007
Test d’infusion lombaire
Sensibilité = 60 à 100%
VPP haute (> 80%)
Mesure de la résistance à l’écoulement du LCS
→ Pose l’indica7on d’une dériva7on
→ Complica7ons limitées
FAUT-IL TRAITER L’HYDROCEPHALIE
7
Hydrocéphalie et Craniectomie
Ryan M et al. J Neurosurgery 2018
Post-craniectomie
80% d’hydrocéphalie
Post-cranioplas8e
↓ 50% des hydrocéphalies
50% → Dérivation interne
Waziri A et al. J Neurosurgery 2007
DERIVATION VENTRICULAIRE ET DOC
7
DoC et dérivaBon
Ventricule latéral
Valve
Tunnélisa0on
Cavité
péritonéale
Kim et al. Chen et al. Huang et al.
39 VS 51 HSA 13 TC
13 ☒ 26 ⇣
GCS suivi 6 mois
+ 0,54 + 2,38*
GOS-score
↑ TC
16 ☒ 35 ⇣
GCS 1-3 mois
6,5 11*
GOS-score 3 mois
2 3*
7 ↑ GOS
5 dans les 3 mois
1 → GOS = 4
Kim, J.Y et al. Journal of Korean Neurotrauma 2006
Chen, Z et al. J Rehabil Med 2014
Huang, X et al. J Craniofac Surg 2014
Pas de CRS-R
DERIVATION VENTRICULAIRE ET DOC
7
DoC et dérivaBon
Kim, J.Y et al. Journal of Korean Neurotrauma 2006
Chen, Z et al. J Rehabil Med 2014
Huang, X et al. J Craniofac Surg 2014
Méningites Décollement HSD
DISCUSSION – PRISE EN CHARGE
EVALUATION CLINIQUE
NEUROIMAGERIE
→ Multiplication de la CRS-R, équipe multidisciplinaire si possible
→ TDM ou IRM à 6S, à 6M ou en cas de détériora8on clinique
7
TEST DIAGNOSTIQUE → Au minimum 1 PL (50mL) / Test d’infusion
CRANIECTOMIE → Considérer la cranioplastie en premier lieu avant dérivation
DERIVATION → Considérer si majora8on de l’HC ou test d’infusion posi8f
CONCLUSION
La prise en charge d’une hydrocéphalie y compris d’appari8on tardive peut
avoir un impact majeur sur la qualité de vie des DOC
L’hydrocéphalie est sous diagnos8quée chez les DOC. L’hydrocéphalie doit
être exclue avant l’évalua8on du statut VS/CMS
L’évaluation clinique régulière et la neuroimagerie en cas de modification de la
clinique est essentielle chez les patients DOC pour diagnostiquer une HC
→
→
→
21
MERCI DE VOTRE ATTENTION,
LE DILEMME DE L’HYDROCEPHALIE CHEZ LES PATIENTS DOC
Dr PIOCHE Pierre-Antoine
NeuroRéanimaBon
28 octobre 2020
SANCY, AUVERGNE

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Pierre-Antoine PIOCHE - Hydrocéphalie et Désordre de Conscience

  • 1. Dr PIOCHE Pierre-Antoine NeuroRéanima7on 🧠 papioche@chu-clermon=errand.fr 28 octobre 2020 LE DILEMME DE L’HYDROCÉPHALIE CHEZ LES PATIENTS PRÉSENTANT UN DÉSORDRE DE CONSCIENCE &
  • 2. INTRODUCTION DEFINITIONS TRAITEMENTS DISCUSSION Désordre de conscience et hydrocéphalie Hydrocéphalie, defini5on Clinique, Radiologique et Test Diagnos5que Cranioplastie, derivation et outcome post hydrocéphalie 2
  • 3. INTRODUCTION Désordre de Conscience 3 Syndromes cliniques DoC Etats végéta7fs (UWS) Etats de conscience minimaux (CMS /MCS)
  • 4. DOC et HYDROCEPHALIE 7 Ischémie HSA HIP / Trauma crânien Trouble de réabsorp7on du LCR
  • 5. DOC après TC ou HSA 50% découverts en rééduca7on 20% DEFINITION DE L’HYDROCEPHALIE 7 Aiguë Subaiguë Chronique H J M Hydrocéphalie (HydroC) et DOC Limite la récupéra7on
  • 6. Atrophie cérébrale progressive INTRODUCTION Hydrocéphalie et DOC 3 Ventriculomégalie LA VENTRICULOMEGALIE EST-ELLE UNIQUEMENT SECONDAIRE A L’ATROPHIE OU A UNE HYDROCEPHALIE ?
  • 7. SUSPECTER UNE HYDROCEPHALIE 7 Clinique de l’HydroC Céphalées Troubles de l’éveil Déclin cogni7f Incon7nence Troubles de la marche CRS-R Fonc%on Audi%ve Fonc%on Visuelle Fonc%on motrice Bi-mensuelle Clinique
  • 8. SUSPECTER UNE HYDROCEPHALIE 7 NeuroImagerie Angle Calleux < 80° Indice d’Evans > 0,3
  • 9. SUSPECTER UNE HYDROCEPHALIE 7 NeuroImagerie Œdème péri-épendymaire Elargissment V. Sylvienne Vide de flux V4 - Aqueduc
  • 10. SUSPECTER UNE HYDROCEPHALIE 7 NeuroImagerie Arterial Spin Labelling SB Périventriculaire Ganglions de la base Thalamus Diminu8on de la perfusion J. Virhammar et al. American Journal of Neuroradiology, 2017
  • 11. SUSPECTER UNE HYDROCEPHALIE 7 NeuroImagerie MR Elastrogaphy N. Fattahi et al. American Journal of Neuroradiology, 2016 Majoration de la rigidité tissulaire
  • 12. HYDROCEPHALIE – TEST DIAGNOSTIQUE 7 Ponction lombaire unique Retrait de 40 à 50 mL Test de ponc8on lombaire unique Sensibilité variable 20-60% Améliora7on des symptômes moteurs Peu ou pas d’effet cognitifs Williams, M.A. and al. Neurology 2013 → Valeur prédic7ve limitée → Pas d’évaluation chez le DoC
  • 13. TESTS DIAGNOSTIQUES 7 Drainage lombaire externe Walchenbach et al. J Neurol Neurosur 2002 Drainage pendant 72h Sensibilité = 50 à 100% VPP = 80-100% → Durée de drainage inconnue pour améliorer l’éveil → Faux-négatifs +++
  • 14. TESTS DIAGNOSTIQUES 7 Test d’infusion lombaire Eklund A et al. Med Biol Eng Comput 2007
  • 15. TESTS DIAGNOSTIQUES 7 Test d’infusion lombaire Eklund A et al. Med Biol Eng Comput 2007 Test d’infusion lombaire Sensibilité = 60 à 100% VPP haute (> 80%) Mesure de la résistance à l’écoulement du LCS → Pose l’indica7on d’une dériva7on → Complica7ons limitées
  • 16. FAUT-IL TRAITER L’HYDROCEPHALIE 7 Hydrocéphalie et Craniectomie Ryan M et al. J Neurosurgery 2018 Post-craniectomie 80% d’hydrocéphalie Post-cranioplas8e ↓ 50% des hydrocéphalies 50% → Dérivation interne Waziri A et al. J Neurosurgery 2007
  • 17. DERIVATION VENTRICULAIRE ET DOC 7 DoC et dérivaBon Ventricule latéral Valve Tunnélisa0on Cavité péritonéale Kim et al. Chen et al. Huang et al. 39 VS 51 HSA 13 TC 13 ☒ 26 ⇣ GCS suivi 6 mois + 0,54 + 2,38* GOS-score ↑ TC 16 ☒ 35 ⇣ GCS 1-3 mois 6,5 11* GOS-score 3 mois 2 3* 7 ↑ GOS 5 dans les 3 mois 1 → GOS = 4 Kim, J.Y et al. Journal of Korean Neurotrauma 2006 Chen, Z et al. J Rehabil Med 2014 Huang, X et al. J Craniofac Surg 2014 Pas de CRS-R
  • 18. DERIVATION VENTRICULAIRE ET DOC 7 DoC et dérivaBon Kim, J.Y et al. Journal of Korean Neurotrauma 2006 Chen, Z et al. J Rehabil Med 2014 Huang, X et al. J Craniofac Surg 2014 Méningites Décollement HSD
  • 19. DISCUSSION – PRISE EN CHARGE EVALUATION CLINIQUE NEUROIMAGERIE → Multiplication de la CRS-R, équipe multidisciplinaire si possible → TDM ou IRM à 6S, à 6M ou en cas de détériora8on clinique 7 TEST DIAGNOSTIQUE → Au minimum 1 PL (50mL) / Test d’infusion CRANIECTOMIE → Considérer la cranioplastie en premier lieu avant dérivation DERIVATION → Considérer si majora8on de l’HC ou test d’infusion posi8f
  • 20. CONCLUSION La prise en charge d’une hydrocéphalie y compris d’appari8on tardive peut avoir un impact majeur sur la qualité de vie des DOC L’hydrocéphalie est sous diagnos8quée chez les DOC. L’hydrocéphalie doit être exclue avant l’évalua8on du statut VS/CMS L’évaluation clinique régulière et la neuroimagerie en cas de modification de la clinique est essentielle chez les patients DOC pour diagnostiquer une HC → → → 21
  • 21. MERCI DE VOTRE ATTENTION, LE DILEMME DE L’HYDROCEPHALIE CHEZ LES PATIENTS DOC Dr PIOCHE Pierre-Antoine NeuroRéanimaBon 28 octobre 2020 SANCY, AUVERGNE