This document provides information on the surgical management of normal pressure hydrocephalus (NPH). It discusses the history and examination findings suggestive of NPH, describes imaging techniques used for diagnosis, and outlines special tests that can aid in evaluation. It also reviews the options for surgical treatment, including ventriculoperitoneal, lumboperitoneal, and endoscopic third ventriculostomy procedures. Factors influencing shunt responsiveness are summarized, and guidelines for proceeding to shunt placement based on diagnostic classification are presented.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
This document discusses different types of brain herniation seen on imaging. The most common types are subfalcine herniation and descending transtentorial herniation. Subfalcine herniation occurs when one hemisphere pushes across the midline under the falx cerebri. Descending transtentorial herniation occurs when the temporal lobe and hippocampus herniate through the tentorial incisura. Other types discussed include tonsillar herniation, ascending transtentorial herniation, and rare transdural herniations. Complications of herniations include hydrocephalus, nerve compression, and infarcts.
Intracerebral hemorrhage (ICH) accounts for 10-15% of strokes and has a high 30-day mortality rate of around 50%. The main causes of ICH are hypertension, vascular malformations, tumors, bleeding disorders, anticoagulants, and head trauma. CT and MRI are used to image ICH, with CT being the initial imaging method. On CT and MRI, ICH has characteristic appearances that change over time from hyperacute to chronic stages as the blood breaks down.
1) A 48-year old man experienced sudden weakness in his left arm and leg, double vision, and loss of vibratory and positional sense on the left side. Exam found spastic paresis of the left extremities, ataxic gait, and paralysis of conjugate gaze to the right.
2) A 55-year old man fell unable to move his right arm and leg. Exam found diminished strength, increased reflexes, and clonus in the right extremities, and uncoordinated movements of the left extremities. He was unable to elevate his mouth or blow out his right cheek upon smiling.
3) An MRI showed a bilateral hyperintense signal in
Cisterns of brain and its contents along with its classification and approach...Rajeev Bhandari
This presentation tell us about the basic of cistern , according to its classification both supra tentorial and infratentorial along with ventral and dorsal cistern. basically the cistern contains are well explained on this slide nerve , artery and vein. I hope it will help to rembember well about the contains of cistern and different location of cisterns.
Intracerebral hemorrhage is an acute extravasation of blood into the brain parenchyma that may extend into ventricles or subarachnoid space. It accounts for 10-15% of strokes and has a 6-month mortality rate of 30-50%. The most common causes are hypertension (78-88%) and cerebral amyloid angiopathy. Treatment involves controlling blood pressure, treating the underlying cause, preventing hematoma expansion, and managing complications. While early surgery was not shown to improve outcomes in the overall STICH trial, it may be beneficial for lobar hemorrhages, which ISTICH-II aims to further evaluate.
Intracranial pressure - waveforms and monitoringjoemdas
The document discusses intracranial pressure (ICP) waveforms and monitoring. It defines the components of the intracranial vault and describes the normal ICP waveform consisting of P1, P2, and P3 waves representing arterial pulsation, intracranial compliance, and venous pulsation, respectively. It also discusses Lundberg waves including A waves resulting from increased cerebrovascular volume due to vasodilation, B waves related to respiratory fluctuations in PaCO2, and C waves corresponding to Traube-Hering-Meyer fluctuations. The gold standard for ICP monitoring is external ventricular drainage connected to an external strain gauge, which allows CSF drainage but carries risks of infection and hemorrhage. Int
This document discusses different types of brain herniation seen on imaging. The most common types are subfalcine herniation and descending transtentorial herniation. Subfalcine herniation occurs when one hemisphere pushes across the midline under the falx cerebri. Descending transtentorial herniation occurs when the temporal lobe and hippocampus herniate through the tentorial incisura. Other types discussed include tonsillar herniation, ascending transtentorial herniation, and rare transdural herniations. Complications of herniations include hydrocephalus, nerve compression, and infarcts.
Intracerebral hemorrhage (ICH) accounts for 10-15% of strokes and has a high 30-day mortality rate of around 50%. The main causes of ICH are hypertension, vascular malformations, tumors, bleeding disorders, anticoagulants, and head trauma. CT and MRI are used to image ICH, with CT being the initial imaging method. On CT and MRI, ICH has characteristic appearances that change over time from hyperacute to chronic stages as the blood breaks down.
1) A 48-year old man experienced sudden weakness in his left arm and leg, double vision, and loss of vibratory and positional sense on the left side. Exam found spastic paresis of the left extremities, ataxic gait, and paralysis of conjugate gaze to the right.
2) A 55-year old man fell unable to move his right arm and leg. Exam found diminished strength, increased reflexes, and clonus in the right extremities, and uncoordinated movements of the left extremities. He was unable to elevate his mouth or blow out his right cheek upon smiling.
3) An MRI showed a bilateral hyperintense signal in
Cisterns of brain and its contents along with its classification and approach...Rajeev Bhandari
This presentation tell us about the basic of cistern , according to its classification both supra tentorial and infratentorial along with ventral and dorsal cistern. basically the cistern contains are well explained on this slide nerve , artery and vein. I hope it will help to rembember well about the contains of cistern and different location of cisterns.
Intracerebral hemorrhage is an acute extravasation of blood into the brain parenchyma that may extend into ventricles or subarachnoid space. It accounts for 10-15% of strokes and has a 6-month mortality rate of 30-50%. The most common causes are hypertension (78-88%) and cerebral amyloid angiopathy. Treatment involves controlling blood pressure, treating the underlying cause, preventing hematoma expansion, and managing complications. While early surgery was not shown to improve outcomes in the overall STICH trial, it may be beneficial for lobar hemorrhages, which ISTICH-II aims to further evaluate.
This document discusses critical illness polyneuropathy and myopathy (ICU-acquired weakness). It begins by defining these conditions and noting their prevalence among critically ill patients. Risk factors include prolonged mechanical ventilation, sepsis, multi-organ failure, and high doses of corticosteroids or neuromuscular blocking agents. The pathophysiology involves systemic inflammation impairing nerve and muscle function through various mechanisms. Clinically, ICUAW presents as a generalized, symmetrical weakness developing after critical illness onset. Investigations can include nerve conduction studies, electromyography, and muscle/nerve biopsies to differentiate between polyneuropathy and myopathy. Management focuses on preventing ICUAW by minimizing risk factors like intensive insulin therapy and limiting neu
This document discusses normal pressure hydrocephalus (NPH), a potentially reversible cause of significant morbidities. NPH is characterized by a triad of gait disturbance, urinary incontinence, and dementia. It can be idiopathic or secondary to other conditions like subarachnoid hemorrhage. Diagnosis involves imaging showing enlarged ventricles without cortical atrophy, along with improvement of symptoms after CSF drainage. Shunting procedures may benefit those without severe white matter lesions or dementia, but have high complication rates. The prognosis for NPH is generally poor.
Cerebral salt-wasting syndrome is characterized by hyponatremia and extracellular fluid depletion due to impaired sodium reabsorption in the kidney caused by brain injury or disease. It mimics the lab findings of SIADH but can be distinguished by clinical signs of volume depletion. Treatment involves correcting the volume depletion with intravenous saline and sodium replacement, along with mineralocorticoid therapy when needed. The condition usually resolves within a few weeks but accurate diagnosis is important since management differs from SIADH.
Trans-cranial Doppler (TCD) ultrasonography is used to evaluate blood flow velocities in the basal intracerebral arteries. It was introduced in 1982 and has since been used for applications like detecting vasospasm after subarachnoid hemorrhage, monitoring stroke risk in sickle cell disease, and as a supplementary test for confirming brain death. TCD uses acoustic windows to insonate arteries like the middle cerebral artery, assessing flow parameters like peak systolic velocity to evaluate stenosis or vasomotor reactivity. It can also detect embolic signals and changes in flow patterns associated with conditions like atrial fibrillation or cerebral circulatory arrest.
The document provides guidance on approaching and managing a comatose patient. It outlines that the primary objectives are to stabilize, evaluate, and treat the patient by taking an organized sequential approach that prioritizes the airway, breathing, circulation, treating metabolic causes of coma like hypoglycemia, and evaluating for increased intracranial pressure or mass lesions. Secondary objectives include understanding the signs and symptoms of different causes of coma and developing a differential diagnosis. The document then provides detailed information on assessing different aspects of the comatose patient including their level of consciousness, neurological exam findings, breathing patterns, eye movements, motor response, and appropriate investigations.
1. Cerebral edema occurs when there is abnormal accumulation of fluid in the brain parenchyma, increasing brain volume and intracranial pressure.
2. It can be caused by traumatic brain injury, stroke, tumors, or other conditions that disrupt the blood-brain barrier.
3. Increased intracranial pressure from cerebral edema can cause neurological deterioration and herniation if not treated.
4. Management involves controlling intracranial pressure, optimizing ventilation and oxygenation, administering osmotherapy agents like mannitol to draw water out of the brain, and in severe cases surgery may be needed.
1) The document discusses signs associated with lesions in the frontal and parietal lobes. Tests are described to assess functions localized to these regions like motor skills, memory, attention, and language abilities.
2) Parietal lobe signs include sensory deficits, agnosias like finger agnosia, and apraxias involving how to complete tasks. Tests evaluate two-point discrimination, graphesthesia, and stereognosis.
3) Both lobes are involved in executive functions and attention. Tests mentioned include the Wisconsin Card Sorting Test, Trail Making Test, and Stroop Test.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Presentation1.pptx, radiological imaging of hydrocephalus.Abdellah Nazeer
This document discusses radiological imaging techniques for evaluating hydrocephalus. It describes various imaging findings in different types of hydrocephalus like congenital hydrocephalus and hydrocephalus secondary to tumors. It focuses on techniques for evaluating normal pressure hydrocephalus (NPH), including phase contrast MRI to quantify cerebrospinal fluid flow. It hypothesizes that NPH may be caused by a combination of naturally enlarged ventricles and later deep white matter ischemia restricting CSF flow, leading to symptomatic hydrocephalus. Quantitative CSF flow studies can help diagnose shunt-responsive NPH.
Coma is defined and the anatomy of consciousness explained. The various levels of arousal, AVPU scale and Glasgow Coma Scale described. The differential diagnosis of coma discussed are coma with & without focal deficits and the meningitis syndrome.
The various aspects of history discussed in details. The examination part includes the general examination, Brainstem reflexes, motor functions with the signs of lateralisation and meningeal irritation signs.
The basic lab investigations, Imaging and special investigations like CSF examination, EEG discussed.
Elevated intracranial pressure and its management explained.
The document describes the anatomy and relationships of the tentorium cerebelli. It is a extension of dura that separates the occipital lobes from the cerebellum. It forms the anterior, middle, and posterior incisural spaces which contain neural, vascular, and cerebrospinal fluid structures. The anterior incisural space contains parts of the circle of Willis and optic structures. The middle incisural space contains cranial nerves 4 and 5 and relates to the temporal horn. The posterior incisural space contains the vein of Galen and quadrigeminal cistern. Herniation can occur through these spaces which can compress surrounding structures.
The document discusses surgical approaches to pineal region tumors. It outlines the boundaries and venous drainage of the pineal region, noting it is located in the diencephalic roof between the habenular commissure and posterior commissure. It describes the surgical anatomy, noting most tumors arise from or are attached to the underside of the velum interpositum and are centered at the pineal gland. Complications of a supratentorial approach are also mentioned.
A brief overview of pituitary adenomas, their subtypes, classification, investigation protocols, radiological evaluation, and their medical management.
Temporal lobe epilepsy is one of the most common forms of epilepsy. It can be caused by hippocampal sclerosis or lesions in the temporal lobe. Hippocampal sclerosis involves neuronal loss and gliosis in the hippocampus and is the most common pathological finding in temporal lobe epilepsy patients. Interictal EEG findings like temporal intermittent rhythmic delta activity and temporal sharp waves help lateralize the seizure focus. Video EEG monitoring helps capture seizures and interictal discharges. Treatment involves antiepileptic drugs and potentially resective surgery for drug-resistant cases.
The document discusses patterns of brain enhancement seen on MRI or CT after contrast administration. It describes 6 common patterns: 1) Periventricular enhancement which can be seen in conditions like lymphoma, infections, or multiple sclerosis. 2) Gyriform enhancement seen in herpes encephalitis, infarcts, or PRES. 3) Nodular subcortical enhancement typically seen in metastatic disease. 4) Ring enhancement commonly from abscesses, metastases, or high grade tumors. 5) Pachymeningeal enhancement of the dura. 6) Leptomeningeal enhancement of the pia-arachnoid membranes. Normal structures that enhance include the choroid plexus, pituitary gland, pineal
This document discusses subarachnoid hemorrhage (SAH), which occurs when there is bleeding into the space between the brain and the thin tissues that cover the brain. The most common cause of SAH is the rupture of an intracranial aneurysm, which affects around 25,000-30,000 people in the US each year. The initial mortality rate is around 45% and over half of survivors are left with major neurological deficits. Diagnosis involves CT scans, lumbar puncture, and angiography. Treatment focuses on surgical clipping or coiling of the aneurysm as well as managing complications like vasospasm, hydrocephalus, and rebleeding through medical therapy.
The subarachnoid space is located between the arachnoid membrane and pia mater in the brain. It contains cerebrospinal fluid and spongy connective tissue. Bleeding into this space is called a subarachnoid hemorrhage (SAH), which is often caused by the rupture of an intracranial aneurysm. CT and MRI are used to detect SAH. Treatment involves relieving vasospasm, removing blood, and clipping or coiling the aneurysm to prevent rebleeding. Complications include hydrocephalus, infarction, and herniation. The mortality rate of SAH is 30-60% even after reaching the hospital.
Mid brain anatomy and vascular syndromesNeurologyKota
The document discusses midbrain syndromes caused by lesions in different areas of the midbrain. It describes the anatomy and vascular supply of the midbrain. It then explains several midbrain syndromes - Parinaud's syndrome causes limited upward gaze; Claude's syndrome results in ipsilateral oculomotor palsy and contralateral ataxia; Benedikt's syndrome includes oculomotor palsy, ataxia, and contralateral hemiparesis; Weber's syndrome involves CN III palsy, contralateral hemiparesis and lower facial weakness. Nothnagel's syndrome involves oculomotor palsy and ipsilateral ataxia. The midbrain contains the superior and inferior
This document provides an outline on the clinical evaluation of adult hydrocephalus. It discusses the classification and etiology of hydrocephalus, including communicating, noncommunicating, and normal pressure hydrocephalus. Pathophysiology and signs/symptoms are described. Neuroradiologic features and physiologic testing of cerebrospinal fluid dynamics are outlined. Management approaches include surgical options like shunt insertion and endoscopic third ventriculostomy. Complications of shunt surgery like infection, overdrainage, and malfunction are also reviewed.
This document discusses cerebrospinal fluid (CSF) dynamics, including CSF production, drainage, composition, and pressure. Key points include:
- CSF is produced by the choroid plexus at a rate of 0.3-0.4 ml/min and is absorbed through the arachnoid villi and dural sinusoids.
- Normal CSF pressure in adults is 4.5-13.5 mmHg.
- Infusion tests can assess CSF system dynamics by measuring parameters like conductance and compliance.
- Understanding CSF dynamics helps research hydrocephalus and could aid in deciding treatment like shunt surgery.
This document discusses critical illness polyneuropathy and myopathy (ICU-acquired weakness). It begins by defining these conditions and noting their prevalence among critically ill patients. Risk factors include prolonged mechanical ventilation, sepsis, multi-organ failure, and high doses of corticosteroids or neuromuscular blocking agents. The pathophysiology involves systemic inflammation impairing nerve and muscle function through various mechanisms. Clinically, ICUAW presents as a generalized, symmetrical weakness developing after critical illness onset. Investigations can include nerve conduction studies, electromyography, and muscle/nerve biopsies to differentiate between polyneuropathy and myopathy. Management focuses on preventing ICUAW by minimizing risk factors like intensive insulin therapy and limiting neu
This document discusses normal pressure hydrocephalus (NPH), a potentially reversible cause of significant morbidities. NPH is characterized by a triad of gait disturbance, urinary incontinence, and dementia. It can be idiopathic or secondary to other conditions like subarachnoid hemorrhage. Diagnosis involves imaging showing enlarged ventricles without cortical atrophy, along with improvement of symptoms after CSF drainage. Shunting procedures may benefit those without severe white matter lesions or dementia, but have high complication rates. The prognosis for NPH is generally poor.
Cerebral salt-wasting syndrome is characterized by hyponatremia and extracellular fluid depletion due to impaired sodium reabsorption in the kidney caused by brain injury or disease. It mimics the lab findings of SIADH but can be distinguished by clinical signs of volume depletion. Treatment involves correcting the volume depletion with intravenous saline and sodium replacement, along with mineralocorticoid therapy when needed. The condition usually resolves within a few weeks but accurate diagnosis is important since management differs from SIADH.
Trans-cranial Doppler (TCD) ultrasonography is used to evaluate blood flow velocities in the basal intracerebral arteries. It was introduced in 1982 and has since been used for applications like detecting vasospasm after subarachnoid hemorrhage, monitoring stroke risk in sickle cell disease, and as a supplementary test for confirming brain death. TCD uses acoustic windows to insonate arteries like the middle cerebral artery, assessing flow parameters like peak systolic velocity to evaluate stenosis or vasomotor reactivity. It can also detect embolic signals and changes in flow patterns associated with conditions like atrial fibrillation or cerebral circulatory arrest.
The document provides guidance on approaching and managing a comatose patient. It outlines that the primary objectives are to stabilize, evaluate, and treat the patient by taking an organized sequential approach that prioritizes the airway, breathing, circulation, treating metabolic causes of coma like hypoglycemia, and evaluating for increased intracranial pressure or mass lesions. Secondary objectives include understanding the signs and symptoms of different causes of coma and developing a differential diagnosis. The document then provides detailed information on assessing different aspects of the comatose patient including their level of consciousness, neurological exam findings, breathing patterns, eye movements, motor response, and appropriate investigations.
1. Cerebral edema occurs when there is abnormal accumulation of fluid in the brain parenchyma, increasing brain volume and intracranial pressure.
2. It can be caused by traumatic brain injury, stroke, tumors, or other conditions that disrupt the blood-brain barrier.
3. Increased intracranial pressure from cerebral edema can cause neurological deterioration and herniation if not treated.
4. Management involves controlling intracranial pressure, optimizing ventilation and oxygenation, administering osmotherapy agents like mannitol to draw water out of the brain, and in severe cases surgery may be needed.
1) The document discusses signs associated with lesions in the frontal and parietal lobes. Tests are described to assess functions localized to these regions like motor skills, memory, attention, and language abilities.
2) Parietal lobe signs include sensory deficits, agnosias like finger agnosia, and apraxias involving how to complete tasks. Tests evaluate two-point discrimination, graphesthesia, and stereognosis.
3) Both lobes are involved in executive functions and attention. Tests mentioned include the Wisconsin Card Sorting Test, Trail Making Test, and Stroop Test.
The document discusses coma, including its definition, causes, clinical assessment, investigations, differential diagnosis and management. Coma is characterized by a total lack of arousal and awareness lasting at least 1 hour. It can be caused by structural brain injuries or metabolic derangements and represents a severe impairment of cerebral function. A systematic clinical approach is needed to identify treatable causes of coma such as head injuries, infections, drugs or toxic exposures.
Presentation1.pptx, radiological imaging of hydrocephalus.Abdellah Nazeer
This document discusses radiological imaging techniques for evaluating hydrocephalus. It describes various imaging findings in different types of hydrocephalus like congenital hydrocephalus and hydrocephalus secondary to tumors. It focuses on techniques for evaluating normal pressure hydrocephalus (NPH), including phase contrast MRI to quantify cerebrospinal fluid flow. It hypothesizes that NPH may be caused by a combination of naturally enlarged ventricles and later deep white matter ischemia restricting CSF flow, leading to symptomatic hydrocephalus. Quantitative CSF flow studies can help diagnose shunt-responsive NPH.
Coma is defined and the anatomy of consciousness explained. The various levels of arousal, AVPU scale and Glasgow Coma Scale described. The differential diagnosis of coma discussed are coma with & without focal deficits and the meningitis syndrome.
The various aspects of history discussed in details. The examination part includes the general examination, Brainstem reflexes, motor functions with the signs of lateralisation and meningeal irritation signs.
The basic lab investigations, Imaging and special investigations like CSF examination, EEG discussed.
Elevated intracranial pressure and its management explained.
The document describes the anatomy and relationships of the tentorium cerebelli. It is a extension of dura that separates the occipital lobes from the cerebellum. It forms the anterior, middle, and posterior incisural spaces which contain neural, vascular, and cerebrospinal fluid structures. The anterior incisural space contains parts of the circle of Willis and optic structures. The middle incisural space contains cranial nerves 4 and 5 and relates to the temporal horn. The posterior incisural space contains the vein of Galen and quadrigeminal cistern. Herniation can occur through these spaces which can compress surrounding structures.
The document discusses surgical approaches to pineal region tumors. It outlines the boundaries and venous drainage of the pineal region, noting it is located in the diencephalic roof between the habenular commissure and posterior commissure. It describes the surgical anatomy, noting most tumors arise from or are attached to the underside of the velum interpositum and are centered at the pineal gland. Complications of a supratentorial approach are also mentioned.
A brief overview of pituitary adenomas, their subtypes, classification, investigation protocols, radiological evaluation, and their medical management.
Temporal lobe epilepsy is one of the most common forms of epilepsy. It can be caused by hippocampal sclerosis or lesions in the temporal lobe. Hippocampal sclerosis involves neuronal loss and gliosis in the hippocampus and is the most common pathological finding in temporal lobe epilepsy patients. Interictal EEG findings like temporal intermittent rhythmic delta activity and temporal sharp waves help lateralize the seizure focus. Video EEG monitoring helps capture seizures and interictal discharges. Treatment involves antiepileptic drugs and potentially resective surgery for drug-resistant cases.
The document discusses patterns of brain enhancement seen on MRI or CT after contrast administration. It describes 6 common patterns: 1) Periventricular enhancement which can be seen in conditions like lymphoma, infections, or multiple sclerosis. 2) Gyriform enhancement seen in herpes encephalitis, infarcts, or PRES. 3) Nodular subcortical enhancement typically seen in metastatic disease. 4) Ring enhancement commonly from abscesses, metastases, or high grade tumors. 5) Pachymeningeal enhancement of the dura. 6) Leptomeningeal enhancement of the pia-arachnoid membranes. Normal structures that enhance include the choroid plexus, pituitary gland, pineal
This document discusses subarachnoid hemorrhage (SAH), which occurs when there is bleeding into the space between the brain and the thin tissues that cover the brain. The most common cause of SAH is the rupture of an intracranial aneurysm, which affects around 25,000-30,000 people in the US each year. The initial mortality rate is around 45% and over half of survivors are left with major neurological deficits. Diagnosis involves CT scans, lumbar puncture, and angiography. Treatment focuses on surgical clipping or coiling of the aneurysm as well as managing complications like vasospasm, hydrocephalus, and rebleeding through medical therapy.
The subarachnoid space is located between the arachnoid membrane and pia mater in the brain. It contains cerebrospinal fluid and spongy connective tissue. Bleeding into this space is called a subarachnoid hemorrhage (SAH), which is often caused by the rupture of an intracranial aneurysm. CT and MRI are used to detect SAH. Treatment involves relieving vasospasm, removing blood, and clipping or coiling the aneurysm to prevent rebleeding. Complications include hydrocephalus, infarction, and herniation. The mortality rate of SAH is 30-60% even after reaching the hospital.
Mid brain anatomy and vascular syndromesNeurologyKota
The document discusses midbrain syndromes caused by lesions in different areas of the midbrain. It describes the anatomy and vascular supply of the midbrain. It then explains several midbrain syndromes - Parinaud's syndrome causes limited upward gaze; Claude's syndrome results in ipsilateral oculomotor palsy and contralateral ataxia; Benedikt's syndrome includes oculomotor palsy, ataxia, and contralateral hemiparesis; Weber's syndrome involves CN III palsy, contralateral hemiparesis and lower facial weakness. Nothnagel's syndrome involves oculomotor palsy and ipsilateral ataxia. The midbrain contains the superior and inferior
This document provides an outline on the clinical evaluation of adult hydrocephalus. It discusses the classification and etiology of hydrocephalus, including communicating, noncommunicating, and normal pressure hydrocephalus. Pathophysiology and signs/symptoms are described. Neuroradiologic features and physiologic testing of cerebrospinal fluid dynamics are outlined. Management approaches include surgical options like shunt insertion and endoscopic third ventriculostomy. Complications of shunt surgery like infection, overdrainage, and malfunction are also reviewed.
This document discusses cerebrospinal fluid (CSF) dynamics, including CSF production, drainage, composition, and pressure. Key points include:
- CSF is produced by the choroid plexus at a rate of 0.3-0.4 ml/min and is absorbed through the arachnoid villi and dural sinusoids.
- Normal CSF pressure in adults is 4.5-13.5 mmHg.
- Infusion tests can assess CSF system dynamics by measuring parameters like conductance and compliance.
- Understanding CSF dynamics helps research hydrocephalus and could aid in deciding treatment like shunt surgery.
A 73-year-old man presented with a 3-year history of progressive memory loss, poor balance, and recent urinary incontinence. Examination showed impaired memory and difficulties with calculations and gait. Brain imaging showed enlarged ventricles and white matter changes. Laboratory tests did not reveal a treatable cause of dementia. The patient's gait improved transiently after lumbar puncture. This document discusses normal pressure hydrocephalus (NPH) and reviews tests to diagnose NPH such as CSF pressure measurement, CSF removal tests, and CSF resistance measurement. It also discusses predictors of shunt response and treatment options for NPH.
The document summarizes various physiologic tests that can be used to assess pelvic floor and anorectal disorders. It describes tests such as manometry, defecography, anal ultrasound, and tests of transit time. For each test, it provides details on the technique, indications for use, preparation, interpretation of results, and how the tests can help diagnose conditions like incontinence, constipation, and pain. The tests provide objective measures that can confirm diagnoses and evaluate treatments. When used together, the tests provide complementary information to fully assess pelvic floor and bowel function.
1) Hydrocephalus is a condition where excess cerebrospinal fluid accumulates in the brain's ventricles, increasing intracranial pressure. It can be treated with shunt surgery but complications are common.
2) Understanding cerebrospinal fluid dynamics is important for diagnosing hydrocephalus and predicting outcomes from shunt surgery. Cerebrospinal fluid flow and pulsatility are assessed using techniques like infusion tests and MRI.
3) Shunt selection is challenging in normal pressure hydrocephalus given variability in intracranial pressure and cerebrospinal fluid dynamics between patients. Adjustable valves allow non-invasive management of complications.
1. Stroke is the third leading cause of death globally and its incidence is increasing in India due to risk factors like aging, smoking, and dietary habits.
2. The majority of strokes are ischemic (87%) with atrial fibrillation being the leading cause, and the rest are hemorrhagic.
3. Timely management following the stroke chain of survival - detection, dispatch, delivery, door, data, decision, drug, and disposition - can help improve outcomes. This includes administration of intravenous thrombolysis within 4.5 hours.
This seminar discusses various physiologic tests used to assess pelvic floor and anorectal disorders, including manometry, defecography, anal ultrasound, MRI, and EMG. Manometry measures anorectal pressures and reflexes and can diagnose sphincter defects, constipation, and pain syndromes. Defecography evaluates anorectal anatomy and function during defecation. Anal ultrasound and MRI identify anatomical abnormalities of the anal sphincters. EMG assesses the integrity of the anal sphincter muscle and its nerve supply. These tests provide objective data to diagnose disorders and monitor treatments like biofeedback or surgery.
This document provides information about intracranial pressure (ICP) monitoring. It defines ICP and normal ranges, and discusses the historical understanding of cerebrospinal fluid circulation dating back to the 18th century work of Magendie. It also summarizes the Monroe-Kelly doctrine which established the concept of a fixed intracranial volume. The document reviews various techniques for ICP monitoring including invasive methods like external ventricular drains and fiberoptic monitors as well as non-invasive options like MRI, ultrasound, and optic nerve sheath diameter measurement. Key aspects of ICP waveform analysis are also summarized.
This document discusses pulsatile versus non-pulsatile perfusion during cardiopulmonary bypass. Pulsatile perfusion is considered more physiologic as it simulates the pulsatile blood flow generated by the human heart. Pulsatile flow is associated with better organ function outcomes and increased microcirculation. It works through increasing surplus hemodynamic energy, maintaining capillary patency above the critical closing pressure, and stimulating neuroendocrine reflexes. Systems that can generate pulsatile flow include ventricular pumps, compression plate pumps, and pulsatile assist devices. However, transmitting pulsatile flow through the cardiopulmonary bypass circuit can be challenging due to pressure losses across components.
1) Normal pressure hydrocephalus (NPH) is characterized by abnormal gait, urinary incontinence, and dementia. It is most common in the elderly and can be caused by conditions like subarachnoid hemorrhage.
2) Diagnosis involves evaluating symptoms, imaging tests showing disproportionate ventricle enlargement, and tests like lumbar puncture to check CSF pressure and flow.
3) Treatment usually involves surgically placing a CSF shunt if symptoms improve with temporary drainage, with benefits seen in 50-61% of cases but also a high risk of complications.
Normal pressure hydrocephalus (NPH) - Dr Sameep Koshti (Consultant Neurosurgeon)Sameep Koshti
This document discusses normal pressure hydrocephalus (NPH), also known as Hakim-Adams syndrome. It defines NPH as a clinical syndrome characterized by a triad of altered mentation, gait difficulties, and sphincter disturbances, along with ventriculomegaly and normal cerebrospinal fluid pressure. The causes of NPH are often idiopathic but can include infection, hemorrhage, trauma, or other obstructions. Diagnosis involves evaluating history, clinical symptoms, physiological tests like lumbar puncture pressure, and brain imaging showing ventricle enlargement. Potential treatments include lumbar drainage tests and placement of a ventriculoperitoneal shunt, usually with a medium-pressure
This document discusses shock, sepsis management, and fluid resuscitation. It addresses:
1) Types of shock including hypovolemic, distributive, obstructive, cardiogenic, and neurogenic.
2) Principles of fluid resuscitation including increasing preload to improve stroke volume and cardiac output. However, fluid boluses only improve cardiac output in about 50% of ICU patients.
3) Dynamic measures like pulse pressure variation, stroke volume variation, passive leg raise, and echocardiography changes after fluid bolus are better than static measures at predicting fluid responsiveness.
- The document describes several case studies involving patients with heart failure:
- The first case involves a 62-year-old woman admitted for acute decompensated heart failure. After 5 days of IV diuresis resulting in weight loss of 8L, her creatinine increased. The best next step would be to stop IV diuresis and re-check labs the next day.
- The second case describes a 74-year-old man with heart failure who was readmitted for worsening symptoms. He underwent evaluation and was found to have constrictive pericarditis, which was treated with surgery.
- The document provides details on these cases and discusses topics like diagnosing and treating acute
This document provides an overview of pulmonary embolism (PE), including its definition, risk factors, types, natural history, symptoms, signs, investigations, diagnosis, and management. PE is defined as obstruction of the pulmonary artery or its branches by material such as thrombus. It discusses diagnostic tests like CT, VQ scan, echocardiogram and their role in determining pretest probability. Management involves anticoagulation with drugs like heparin, warfarin, rivaroxaban. Thrombolysis may be used for massive PE while inferior vena cava filters can be placed in patients who cannot receive anticoagulation.
This document provides an overview of shock, including:
1) Definitions of shock as a syndrome resulting in inadequate tissue perfusion and oxygenation affecting multiple organ systems.
2) Physiology of shock as a complex cascade involving hypoperfusion, inflammation, and organ dysfunction.
3) Treatment approach focusing on airway control, circulation optimization, oxygen delivery, and achieving resuscitation end points.
4) Types of shock like hypovolemic, septic, cardiogenic, anaphylactic, neurogenic, and obstructive shock are described with examples.
This document summarizes sonothrombolysis as an adjuvant treatment for acute ischemic stroke. It discusses how ultrasound enhances the lytic effects of tPA to improve recanalization rates. Sonothrombolysis delivers ultrasound through acoustic windows in the skull to the occlusion site. Ultrasound may improve clot lysis mechanically and by promoting tPA activity. Two phase III trials, CLOTBUST and CLOTBUST-ER, found sonothrombolysis had a good safety profile but no additional clinical benefit over tPA alone. Current guidelines do not recommend sonothrombolysis outside of clinical trials due to lack of proven efficacy.
A 39-year-old woman presented with a severe headache and was found to have signs of subarachnoid hemorrhage (SAH) on further examination and testing. Her level of consciousness then deteriorated and she had a seizure. A repeat head CT showed rebleeding of the SAH along with acute hydrocephalus. Initial management of SAH involves controlling blood pressure, treating hydrocephalus if present, securing the aneurysm within 24 hours to prevent rebleeding, and administering nimodipine to prevent cerebral vasospasm. Close monitoring is needed for any further neurological changes or complications.
Care of patient with external ventricular drainShruti Shirke
Nurses are responsible for caring for patients with external ventricular drains (EVDs) used to treat hydrocephalus and reduce intracranial pressure. EVDs drain excess cerebrospinal fluid from the brain ventricles to an external drainage system. Nurses must carefully monitor fluid drainage and intracranial pressure, watch for signs of infection or blockage, and ensure the EVD system is properly aligned and functioning to safely manage the patient's condition.
Normal pressure hydrocephalus (NPH) is characterized by progressive gait impairment, cognitive deficits, and urinary urgency or incontinence. It is potentially reversible via shunt surgery. NPH is caused by reduced cerebrospinal fluid (CSF) absorption and increased resistance to outflow, leading to increased CSF pulse pressure and cerebral pulsations. Diagnosis involves imaging showing ventriculomegaly and a positive response to CSF drainage tests. Treatment is typically via shunt surgery, though factors like severe dementia or extensive white matter lesions on MRI predict poorer outcomes.
This document provides an overview of urodynamic studies (UDS), which are used to evaluate bladder storage and voiding functions. It describes various UDS techniques including uroflowmetry, post-void residual measurement, cystometry, and pressure-flow studies. Cystometry involves bladder filling while measuring pressures, and is used to assess capacity, compliance, and for detecting detrusor overactivity. Pressure-flow studies performed during voiding provide information about bladder contractility and outflow obstruction. Together these invasive UDS techniques provide valuable information to characterize lower urinary tract dysfunction.
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8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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3. History
• SUGGESTIVE OF NPH
• Insidious onset (versus acute)
• Origin after age 40 yr
• A minimum duration of at least 3 to 6 mo
• No evidence of an antecedent event such as head trauma,
intracerebral hemorrhage, meningitis, or other known causes of
secondary hydrocephalus
• Progression over time
• No other neurological, psychiatric, or general medical conditions that
are sufficient to explain the presenting symptoms
4. Examination
• Gait/balance
• At least two of the following should be present and not be entirely attributable to other
condition
• Decreased step height
• Decreased step length
• Decreased cadence (speed of walking)
• Increased trunk sway during walking
• Widened standing base
• Toes turned outward on walking
• Retropulsion (spontaneous or provoked)
• En bloc turning (turning requiring three or more steps for 180 degrees)
• Impaired walking balance, as evidenced by two or more corrections out of eight steps on
tandem gait testing
5. Gait in NPH
• “Apractic,” “bradykinetic,” “glue-footed,” “magnetic,” “parkinsonian,”
“short-stepped” and “shuffling.”
• Gait problems may emerge as difficulty in ascending or descending stairs.
• Patients may complain of difficulty rising from a chair, “give-way”
weakness of the lower extremities, and fatigue brought on by walking.
• As the disease progresses, turning in place becomes tenuous and
typically requires multiple steps (en bloc).
• The stance in INPH may be more forward leaning than in healthy normal
individuals
• INPH patients tend to show a wider sway and imbalance that may be
accentuated by eye closure
6. Cognition
• Documented impairment in two of following
• Psychomotor slowing (increased response latency)
• Decreased fine motor speed
• Decreased fine motor accuracy
• Difficulty dividing or maintaining attention
• Impaired recall, especially for recent events
• Executive dysfunction, such as impairment in multistep procedures,
working memory, formulation of abstractions/similarities, insight.
• Behavioral or personality changes
7. Urinary continence
• ONE of the following
• Episodic or persistent urinary incontinence not attributable to primary
urological disorders
• Persistent urinary incontinence
• Urinary and fecal incontinence
• TWO of the following
• Urinary urgency as defined by frequent perception of a pressing need to
void
• Urinary frequency as defined by more than six voiding episodes in an
average 12-hour period despite normal fluid intake
• Nocturia as defined by the need to urinate more than two times in an
average night
8. Not seen in NPH
• Papilledema
• Seizure
• Headache
9.
10. Imaging
• Ventricular enlargement
not entirely attributable
to cerebral atrophy or
congenital enlargement
• Evan’s index > 0.3
• No macroscopic CSF
obstruction
12. • Enlargement of the temporal horns of the lateral
ventricles not entirely attributable to hippocampus
atrophy
13. • Evidence of altered brain water content, including periventricular
signal changes on CT and MRI not attributable to microvascular
ischemic changes or demyelination
• White matter changes in the frontal lobe and periventricular region
have the strongest relation to impairments in balance and gait
14. Sagittal MRI
• Measurement of the diameter of the corpus callosum
• Decreases in many cases of INPH as the dorsal
surface of the ventricle domes upward
• Cingulate sulcus sign: Wide or normal cingulate
sulcus in the frontal lobe but compressed at the
posterior part.
• Loss of convexity of upper midbrain
• Aqueductal flow void
16. • An aqueductal or fourth ventricular flow void on MRI
• Fast movement of CSF gives rise to a signal loss on T2-
weighted MRI called the flow void phenomenon
• The flow void is often increased in the cerebral aqueduct and
forth ventricle in NPH.
17. • Coronal MRI
• Calculation of the callosal angle
• Assessment of the perihippocampal morphology
• Useful in distinguishing ventriculomegaly
secondary to cerebral atrophy
20. DESH:Disproportionately Enlarged
Subarachnoid Space Hydrocephalus
Circles: fronto-parietal convexity sulcal effacement and sagittal sinus abutment
Arrows: Enlargement and upward displacement of roof of Sylvian fissure
Not NPH NPH
21.
22.
23.
24. Other radiological tests
• Radionuclide cisternogram showing delayed
clearance of radiotracer over the cerebral
convexities after 48–72 h.
• Cine MRI study or other technique showing
increased ventricular flow rate
• SPECT-acetazolamide challenge showing
decreased periventricular perfusion that is not
altered by acetazolamide
26. Lumbar puncture
• A cerebrospinal fluid (CSF) opening pressure (CSF-OP) as diagnostic purpose
• Measured by lumbar puncture in the lateral recumbent position
• Range of 5–18 mm Hg
• Pressure > 18 mm Hg implies other causes of HCP
• Up to 50 cc of CSF is removed to see if symptoms are temporarily relieved by this
CSF volume reduction.
• If removal of some CSF dramatically improves symptoms, even temporarily, then
surgical treatment is likely to be successful.
• Limitation of lumbar puncture
• Some people may have little or no improvement after the test, and yet may still
improve with a shunt.
• When the response to a lumbar puncture is “negative” or uncertain, further
evaluation may be helpful
27. External lumbar drainage or
continuous lumbar drainage
• It also allows for more accurate recording of CSF pressure and response
• 300 ml to be removed over a 5-day period.
• ELD was initially described by Haan and Thomeer et al and consisted of draining 10
ml of CSF per hour for a period of 72 hours (total, 720 ml).
• Prospective study of ELD reported by Walchenbach et al.
• 49 patients from three hospitals (43 with INPH) were studied. Patients who did
not improve with a tap were given ELD in which 300 ml was removed over a 5-
day period.
• Of 38 patients given ELD, 16 improved after drainage and 22 did not. Of the 16
who were improved after drainage, 14 improved after shunting.
• The overall accuracy of ELD in this study equaled 62%.
Haan J, Thomeer RT: Predictive value of temporary external lumbar drain- age in normal pressure hydrocephalus. Neurosurgery 22:388–391, 1988.
RT, Vanneste J: The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus. J Neurol
28. CSF flow resistance
• The measurement of CSF outflow resistance is a more
involved test that requires a specialized clinical setting.
• The resistance to CSF is considered to be the impedance to flow
offered by the CSF absorption pathways.
• This test begins with a lumbar tap and assesses the degree of
blockage of CSF absorption back into the bloodstream.
• It requires the simultaneous infusion of artificial spinal fluid and
measurement of CSF pressure.
• If the calculated resistance value is abnormally high, then there is a
very good chance that the patient will improve with shunt surgery,
since the shunt mimics the function of the body’s normal CSF
drainage pathways.
29. Method of CSF resistance
study
• ICP measurements used for the calculation of Ro are obtained from a cranial epidural monitor.
• Katzman test
• Pump introduces mock CSF fluid or saline at a known rate through a needle placed in the lumbar
subarachnoid space.
• The Ro, as defined by the Katzman infusion test, is the difference in the final steady-state pressure
reached and the initial pressure divided by the infused flow rate.
• R0 = Pf - Pi/I
• Trakeuchi et al.measureed Ro in 25 shunted INPH patients.
• The average Ro for the shunted group with improved outcome equaled 35.3 mm Hg/ml/min.
• The average value of Ro for the shunted group with no improvement equaled 9.1 mm Hg/ml/min (P <
0.01).
• On the basis of this threshold, the calculated sensitivity and specificity equaled 100 and 92%,
respectively
Takeuchi T, Kasahara E, Iwasaki M, Mima T, Mori K: Indications for shunting in patients with idiopathic normal pressure hydrocephalus presenting with
dementia and brain atrophy (atypical idiopathic normal pressure hydrocephalus). Neurol Med Chir (Tokyo) 40:38–47, 2000.
30. CSF flow study
• It has been proposed that NPH patients have a higher CSF flow velocity through
the cerebral aqueduct.
• This was first noted by an exaggerated aqueductal flow void on axial MRI scans
• Subsequently, methodologies were developed to estimate the actual maximum
flow velocity at that site
• Luetmer et al. suggested that velocities greater than 18 ml/min were predictive for
good outcome after shunting.
• The pathophysiological basis of increased CSF flow void velocity in INPH has not
been established.
• On the basis of current evidence, neither MRI CSF flow void sign nor quantitative
CSF flow velocity seems to have significant diagnostic value.
Luetmer PH, Huston J, Friedman JA, Dixon GR, Petersen RC, Jack CR, McClelland RL, Ebersold MJ: Measurement of cerebrospinal fluid flow at the cerebral aqueduct
by use of phase contrast magnetic resonance imaging: Technique validation and utility in diagnosing idiopathic normal pressure hydrocephalus. Neurosurgery
50:534–544, 2002.
31. ICP monitoring
• In addition to measuring the baseline opening pressure, many have
been interested in possible relationships between continuous ICP
recording variables and outcome for NPH.
• Studies have been done for correlation between the number of B
waves recorded (overnight during sleep) and outcome
• It has been proposed that the increased frequency in B waves is
indicative of lowered compliance and/or may play an important role
in the pathophysiology of the ventriculomegaly and neuronal
dysfunction.
• Class III evidence does not currently support continuous ICP
monitoring to determine the frequency of B or A waves.
• ICP to be measured only when opening pressure on LP is equivocal.
33. Shunt responsiveness
• Considered separately as a measure of treatment outcome and does not enter into
diagnostic classification
• On the basis of clinical presentation alone, evidence shows that favorable response to
shunting will vary from 46 to 63%
• INDICATORS of SHUNT responsiveness
• The onset of gait disturbance as the first and most prominent symptom
• A known cause for NPH, such as trauma or hemorrhage
• The scan (MRI or CT) shows the ventricular size to be disproportionately
• Larger than the CSF in the subarachnoid space
• Removal of spinal fluid via lumbar puncture or lumbar catheter gives dramatic,
temporary relief of symptoms
• ICP or spinal fluid pressure monitoring shows an abnormal range or pattern of spinal
fluid pressure or an elevated CSF outflow resistance
• Minimal evidence of disease of the small blood vessels nourishing the brain
34. GUIDENILE FOR PROCEEDING TO
SHUNT
• On the basis of the history, neurological examination, and basic neuroimaging (CT and/or MRI
scans), the patient is categorized as
• Probable
• Possible
• Unlikely INPH
• Shunt placement for probable and possible INPH with good outcome ranges from 43 - 60 %
• The probability of improvement for an unlikely INPH designation is presumably less
• To avoid complications and improve the certainty of a positive shunt response beyond 50 to 61%,
all probable and possible INPH patients should be considered for supplemental testing.
• One or more of the following three tests is recommended:
• CSF tap test
• Ro determination,
• ELD.
37. Recepient sites
• Peritoneum
• Provides little pressure of its own and allows drainage and reabsorption of a large volume of fluid.
• Cardiac atrium
• Provides an egress for a very large volume of CSF.
• It can also handle high protein content that could cause malabsorption of fluid in the peritoneal space.
• Pleural space
• Generates its own negative pressure.
• This can be used to advantage in constructing a shunting system that provides less-than-normal
pressure or even negative pressure if the valve is chosen appropriately.2
• Antisiphoning components, which prevent negative pressure in the shunt tubing, can be used to
counteract the negative pressure “sink” of the pleural space.
• Gallbladder
• Provides a positive pressure postprandially that prevents over drainage
• Torkildsen shunt (ventricle to the cisternal space)
• Sinushunt (ventricle to the venous sinus).
38. Parts of shunt
• Inlet tubing (ventricular drain),
which is a thin short tube with an
inner diameter of 0.9 to 1.2 mm
• Valve
• Distal drain, a longish silicone
rubber tube
• Acssesories
• Reservoirs, Siphon Devices
• Connectors, Filters, Pumping
Chamber
39. • Silicon membrane—flow is controlled by an elastic membrane that
changes the area of the outlet orifice.
• A simpler, less accurate mechanism consists of a valve mechanism
derived from two apposing semirigid membranes.
• These valves, which include the Medtronic, Pudenz, and Codman distal
slit valves, are manufactured and then individually tested to determine
the approximate opening pressure.
• They are then segregated into different bins covering a range of
pressures.
• Valves - Classified according to their construction
40. • Ball-on-spring—flow depends on compression of a spring(flat
or helical) supporting a ball moving along the cone that
constitutes the outlet orifice.
• It consists of a tiny ball situated on a ring, with a spring
pushing the ball downward on the ring. CSF passes through
the ring, elevating the ball if the pressure exceeds the
pressure exerted by the spring.
• This creates a one-way flow mechanism because reverse flow
will not occur as the ball sits down onto the ring.
• In ball-on-spring valves, this pressure is very stable over time
but is sensitive to dynamic changes in ICP.
• Medtronic Strata valve, the Codman Hakim programmable
and Precision valves, and the Aesculap proGAV valve
• A Proximal or distal slit valves—flow depends on the area of a
slit in soft silicone rubber.
41.
42. Programmable shunt in NPH
• Adults are less able to adapt to a fixed pressure than children, whose brains are
more plastic.
• Opening and closing pressure may be programmed externally
• Strata valve (Medtronic) with a fused antisiphoning chamber
• Codman-Hakim valve, Codman/Johnson & Johnson, NON SIPHONING
• Sophy valve, Sophysa NON SIPHONING
• 3 to 20 cm H2
O by various increments.
43. Shunt insertion
• Ventriculoperitoneal shunt - Frontal or occipital burr hole
• Ventriculo pleural shunt
• Incision at the third or fourth rib off the midline in the same line that we would use for
passage of the peritoneal catheter for a ventriculoperitoneal shunt.
• Then dissect down to the pleura through the muscles of the anterior chest wall and the
intercostal muscles.
• Once the pleura is identified, it is not opened until the shunt is entirely connected.
• Connect the ventricular catheter to the shunting device, visualize distal runoff of CSF,
and then under direct vision make a pleural egress with a long hemostat and place
approximately 20 cm of tubing into the pleural space.
• Placement of a positive end–expiratory pressure valve in the anesthesia circuit to
maintain lung inflation during placement of the pleural catheter and thus avoid
pneumothorax.
44. Ventriculoatrial shunt placement
• Fluoroscopic or angiographic assistance
• Tunnel is made to a point over the internal jugular vein.
• This point is selected by placement of a “finding” needle and then a larger
needle and J wire into the internal jugular vein on the neck lateral to the
sternocleidomastoid muscle.
• Tubing is tunneled to the neck incision to allow the blunt-end catheter tubing
into the cardiac atrium with an additional several centimeters for positioning.
• Once the wire is visualized in the cardiac atrium by fluoroscopy, a 10-Fr
introducer sheath is placed over the wire, the wire is removed, and the tubing
is threaded directly through the introducer sheath into the cardiac atrium
under fluoroscopic guidance.
• Intraoperative cardiac angiography to confirm the placement of the catheter at
the junction between the superior vena cava and the right atrium.
45. Siphoning
• Change in pressure when the patient suddenly stands from
lying posture in siphoning
• ANTI SIPHON DEVICES (ASDs)
• In general, the device is based on a membrane that is
mechanically coupled to the subcutaneous tissue overlying
it.
• When the intraluminal pressure becomes significantly
negative (relative to atmospheric pressure), the membrane
is drawn inward—interacting with other fixed components of
the ASD
46. • Membrane devices (Delta chamber)
• Subcutaneous membrane is designed to
stop drainage when its outlet pressure is
negative
• Could also impede CSF flow when
compressed by tense skin or external
pressure through the skin.
• Flow-regulating (Siphon Guard) device
• Hakim programmable valve
• Limits excessive flow but may
permanently increase the hydrodynamic
resistance of the shunt system to very
high values
• May cause intracranial hypertension
47. Complications
• Shunt Malfunction
• In growth of choroid plexus or other debris into the catheter
• Shunt Infection
• Overdrainage
• Low-pressure headaches
• Small or slit ventricles -
• Subdural collections
• Chronic hematomas
• CSF overdrainage
48. Underdrainage
• Patient presents with recurrence of symptoms
• Removing an antisiphoning component or by replacing a
differential pressure valve with a flow-regulated valve may
sometimes provide additional drainage.
• Revising the terminus of the shunting device from the
peritoneal space to the pleural space, which generates
negative pressure, can improve drainage characteristics
• Ventriculoatrial shunts provide more drainage than
ventriculoperitoneal shunts do, and therefore shunt
revision to a ventriculoatrial shunt can be done.
49. • Subdural heamtoma
• Ventricular collapse and disruption of the subdural
bridging veins, causing subdural hematoma.
• Other complications
• Infection
• Bleeding - Incidence of intracerebral hematoma= 3%
• CSF leakage
• Seizures
50. Post shunt pressure setting
• Theoretical benefit with placing a
shunt with a high differential
pressure and then slowly decreasing
that pressure to a more normal or
even less-than-normal one.
• This may allow better
accommodation and prevent
ventricular collapse from sudden
over drainage
• But some studies have used fixed
pressure setting at 100 mm of h2O
and then then reducing pressure
52. ETV
• Some patients with NPH have a late-onset form of
relative aqueduct stenosis.
• These patients, there is a mismatch between the
degree of ventriculomegaly in the lateral ventricles
and third ventricle and between the aqueduct of
Sylvius and the fourth ventricle.
• Gangemi and coauthors reported improvement in
72% of NPH patients with this technique and a
relatively low complication rate
53.
54. Lumboperitoneal shunt
• Lumboperitoneal (LP) shunt has been used occasionally
• The main reason LP shunt is considered when treating
patients with NPH is the avoidance of the risk of
intracranial hemorrhage while passing a catheter
through the brain parenchyma.
• Higher failure rates compared to ventriculoperitoneal
shunts
• SINPHONI 2 trial of Japan
55.
56. • Published rates of improvement after surgical intervention range from 53% to
78.9%
• 31% of patients who are shunt non responders, have potential overlap with
other neurodegenerative conditions, including Parkinson’s and Alzheimer’s
disease.
• In a study by Pojari et al
• Gait showed the highest improvement over baseline (83% at 3 years and
87% at the last analysed follow-up of 7 years)
• Cognition showed intermediary improvement (84% and 86%, respectively)
• Urinary incontinence showed the least improvement (84% and 80%,
respectively)
jari S, Kharkar S, Metellus P, Shuck J, Williams MA, Rigamonti D. Normal pressure hydrocephalus: long-term outcome after shunt surgery. J Neurol Neurosurg Psychiatry. 2008 Nov;79(11):1282
Outcome
57. • Comorbid AD and iNPH is common
• Increased with the presence of hypertension and
advancing age.
• AD pathology is present in cortical biopsy of 75% of those iNPH
patients with significant dementia at the time of shunt surgery
• Gait can improve with shunting, dementia typically does not.
• Surgical treatment is generally discouraged for patients with
severe dementia, even in the setting of gait dysfunction and
incontinence, regardless of radiographic findings
• Gait is the easiest symptom to assess objectively
• 10m walking test- in which the number of steps taken and the
time necessary to traverse this distance is used to compare
preoperative and postoperative status.
Miller DC, et al. Alzheimer’s disease comorbidity in normal pressure hydrocephalus: prevalence and shunt response. J Neurol Neurosurg Psychiatry 2000