Symptomatic subdural hematoma development is a constant concern for patients who have undergone cerebrospinal fluid shunting procedures to relieve symptoms related to normal-pressure hydrocephalus. Acute subdural hematomas are of particular concern in these patients as even minor head trauma may result in subdural hematoma formation. The presence of a ventricular shunt facilitates further expansion of the subdural hematoma and often necessitates surgical treatment, including subdural hematoma evacuation and shunt ligation.
We present the case of a 63-year-old North American Caucasian man with normal-pressure hydrocephalus with an adjustable valve ventriculoperitoneal shunt who developed an acute subdural hematoma after sustaining head trauma. Conservative treatment was favored over operative evacuation because our patient was neurologically intact, but simple observation was considered to be too high risk in the setting of a low-pressure ventriculoperitoneal shunt. Thus, the valve setting on the ventriculoperitoneal shunt was increased to its maximum pressure setting in order to reduce flow through the shunt and to mildly increase intracranial pressure in an attempt to tamponade any active bleeding and limit hematoma expansion. A repeat computed tomography scan of the head six days after the valve adjustment revealed complete resolution of the acute subdural hematoma. At this time, the valve pressure was reduced to its original setting to treat symptoms of normal-pressure hydrocephalus.
Programmable shunt valves afford the option for non-operative management of acute subdural hematoma in patients with ventricular shunts for normal-pressure hydrocephalus. As illustrated in this case report, increasing the shunt valve pressure may result in rapid resolution of the acute subdural hematoma in some patients.
Normal-pressure hydrocephalus; Ventriculoperitoneal shunt; Acute subdural hematoma; Programmable shunt valve
There is little consensus regarding the indications for surgical CSF diversion (either with implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm infants with posthemorrhagic hydrocephalus. The authors determined clinical and neuroimaging factors associated with the use of surgical CSF diversion among neonates with intraventricular hemorrhage (IVH), and describe variations in practice patterns across 4 large pediatric centers.
The use of implanted temporizing devices and conversion to permanent shunts was examined in a consecutive sample of 110 neonates surgically treated for IVH related to prematurity from the 4 clinical centers of the Hydrocephalus Clinical Research Network (HCRN). Clinical, neuroimaging, and so-called processes of care factors were analyzed.
Seventy-three (66%) of the patients underwent temporization procedures, including 50 ventricular reservoir and 23 subgaleal shunt placements. Center (p < 0.001), increasing ventricular size (p = 0.04), and bradycardia (p = 0.07) were associated with the use of an implanted temporizing device, whereas apnea, occipitofrontal circumference (OFC), and fontanel assessments were not. Implanted temporizing devices were converted to permanent shunts in 65 (89%) of the 73 neonates. Only a full fontanel (p < 0.001) and increased ventricular size (p = 0.002) were associated with conversion of the temporizing devices to permanent shunts, whereas center, OFCs, and clot characteristics were not.
Considerable center variability exists in neurosurgical approaches to temporization of IVH in prematurity within the HCRN; however, variation between centers is not seen with permanent shunting. Increasing ventricular size—rather than classic clinical findings such as increasing OFCs—represents the threshold for either temporization or shunting of CSF.
hydrocephalus; preterm infant; temporizing implant; intraventricular hemorrhage; cerebrospinal fluid shunt; Hydrocephalus Clinical Research Network
Oral anticoagulation therapy (OAT) with warfarin increases mortality and disability after intracerebral hemorrhage (ICH), the result of increased ICH volume and risk of hematoma expansion. We investigated whether OAT also influences risk of development of intraventricular hemorrhage (IVH), the volume of IVH and IVH expansion, and whether IVH is a substantive mediator of the overall effect of OAT on ICH outcome.
We performed a retrospective analysis of a prospectively collected single-center cohort of 1,879 consecutive ICH cases (796 lobar, 865 deep, 153 cerebellar, 15 multiple location, 50 primary IVH) from 1999 to 2009. ICH and IVH volumes at presentation, as well as hematoma expansion (>33% or >6 mL increase) and IVH expansion (>2 mL increase), were determined using established semiautomated methods. Outcome was assessed at 90 days using either the modified Rankin Scale or Glasgow Outcome Scale.
Warfarin use was associated with IVH risk, IVH volume at presentation, and IVH expansion in both lobar and deep ICH (all p < 0.05) in a dose-response relationship with international normalized ratio. Warfarin was associated with poor outcome in both lobar and deep ICH (p < 0.01), and >95% of this effect was accounted for by baseline ICH and IVH volumes, as well as ICH and IVH expansion.
Warfarin increases IVH volume and risk of IVH expansion in lobar and deep ICH. These findings (along with effects on ICH volume and expansion) likely represent the mechanisms by which anticoagulation worsens ICH functional outcome.
Ventriculoperitoneal shunt placement is an effective treatment of hydrocephalus diverting the cerebrospinal fluid into the peritoneal cavity. Unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, 25% of which are abdominal. Spontaneous bowel perforation is a rare potentially fatal complication of ventriculoperitoneal shunt occurring anytime, few weeks to several years, after the placement of the ventriculoperitoneal shunt device. A 54-year-old Greek man with spontaneous perforation of sigmoid colon as a complication of distal ventriculoperitoneal shunt migration was treated successfully by antibiotic prophylaxis and abdominal surgery. Clinicians managing patients with ventriculoperitoneal shunt must be familiar with its possible complications and be aware for early recognition of them.
To determine in extremely low birth weight (ELBW) infants if elevated blood inteferon-γ (IFN-γ), interleukin-1β (IL-1β), IL-18, tumor necrosis factor-α (TNF-α), and transforming growth factor-β (TGFβ) are associated with need for shunt following severe intraventricular hemorrhage (IVH), or with ventricular dilation following milder grades /no IVH.
Whole blood cytokines were measured on postnatal days 1, 3, 7, 14, and 21. Maximum IVH grade in the first 28d, and shunt surgery or ventricular dilation on subsequent ultrasound (28d -36 w PMA) were determined.
Of 902 infants in the NICHD NRN Cytokine study who survived to 36w/discharge, 3.1% had shunts. Of the 12% of infants with severe (Gr III–IV) IVH, 26% had a shunt associated with elevated TNF-α. None of the infants without IVH (69%) or with Gr I (12%) or II (7%) IVH received shunts, but 8.4% developed ventricular dilation, associated with lower IFN-γ and higher IL-18.
Statistically significant but clinically non-discriminatory alterations in blood cytokines were noted in infants with severe IVH who received shunts and in those without severe IVH who developed ventricular dilation. Blood cytokines are likely associated with brain injury but may not be clinically useful as biomarkers for white matter damage.
Infant; premature; Cytokines; Hydrocephalus; Intraventricular hemorrhage; Intracranial hemorrhage
We report neuroendoscopic evacuation of an intraventricular hematoma (IVH) in 13 patients with thalamic hemorrhage. We discuss strategies to improve the outcome and to shorten the management period by using external ventricular drainage (EVD).
Patients were classified into fair (modified Rankin scale [mRS] grade 4 or less) and poor (mRS grade 5) outcome groups, and depending on the duration of EVD, into short (7 days or shorter) and long EVD (8 days or longer) groups.
The postoperative residual IVH, graded using the Graeb score, was better for the fair outcome group than for the poor outcome group (3.9 [1.2] vs. 5.7 [1.0], P < 0.05). The postoperative Graeb score was significantly better for the short EVD group than for the long EVD group (3.6 [0.8] vs. 6.0 [0.6], P < 0.01). The duration of EVD was not correlated with the IVH at the fourth ventricle, but it was correlated with the IVH at the foramen of Monro (P < 0.05) and the third ventricle (P < 0.01). Reduction in the volume of thalamic hemorrhage had no effect on the neurological outcome or duration of EVD.
Neuroendoscopic evacuation of the IVH at the foramen of Monro and the third ventricle shortened the duration of EVD for hydrocephalus caused by thalamic hemorrhage with IVH involvement. Removal of the thalamic hemorrhage and IVH at the fourth ventricle was not necessary.
External ventricular drainage; hydrocephalus; intraventricular hematoma; neuroendoscope; thalamic hemorrhage
Cerebellar hemorrhage remote from the operative site is an unpredictable and rare complication in neurosurgery, with reported rates of morbidity and mortality in the literature of 8.4% and 7.8%, respectively. The range of procedures associated with remote cerebellar hemorrhage is diverse and includes both supratentorial and spinal procedures that entail significant cerebral spinal fluid loss or resection of supratentorial content. We present here the first documented case of remote cerebellar hemorrhage after controlled supratentorial cerebral spinal fluid drainage by ventriculoperitoneal shunt, and discuss the proposed pathophysiology and treatment.
We present the case of a four-month-old Saudi Arabian male baby who presented with progressive symptoms and signs of congenital hydrocephalus. An uneventful ventriculoperitoneal shunting was performed with our patient recovering smoothly in the immediate postoperative period. On the next day, he had frequent episodes of vomiting and became lethargic. An urgent computed tomography scan of his brain revealed mild ventricular decompression and unexpected cerebellar hemorrhage. The infant was put under close observation, with marked spontaneous improvement over 48 hours and complete resolution of the hemorrhage on a follow-up computed tomography brain scan two weeks later. On regular outpatient visits at one, three and twelve months, he had no neurological deficit.
Remote cerebellar hemorrhage is a complication that remains enigmatic in terms of both the underlying mechanism and clinical behavior. Our case revealed that the risk factors identified in the literature are not sufficient in predicting patients at risk of developing remote cerebellar hemorrhage. Our report also adds to the growing body of evidence challenging the currently accepted hypothesis explaining the pathomechanism of remote cerebellar hemorrhage. It thereby remains an unpredictable hazard that requires further study and increased awareness, as many cases in the literature are incidental findings.
Catheter-based evacuation is a novel surgical approach for the treatment of brain hemorrhage. The object of this study was to evaluate the safety and efficacy of ultrasound in combination with recombinant tissue plasminogen activator (rt-PA) delivered through a microcatheter directly into spontaneous intraventricular (IVH) or intracerebral (ICH) hemorrhage in humans.
Thirty-three patients presenting to the Swedish Medical Center in Seattle, Washington, with ICH and IVH were screened between November 21, 2008, and July 13, 2009, for entry into this study. Entry criteria included the spontaneous onset of intracranial hemorrhage ≥ 25 ml and/or IVH producing ventricular obstruction. Nine patients (6 males and 3 females, with an average age of 63 years [range 38–83 years]) who met the entry criteria consented to participate and were entered into the trial. A ventricular drainage catheter and an ultrasound microcatheter were stereotactically delivered together, directly into the IVH or ICH. Recombinant tissue plasminogen activator and 24 hours of continuous ultrasound were delivered to the clot. Gravity drainage was performed. In patients with IVHs, 3 mg of rt-PA was injected; in patients with intraparenchymal hemorrhages, 0.9 mg of rt-PA was injected. The rt-PA was delivered in 3 doses over 24 hours.
All patients had significant volume reductions in the treated hemorrhage. The mean percentage volume reduction after 24 hours of therapy, as determined on CT and compared with pretreatment stability scans, was 59 ± 5% (mean ± SEM) for ICH and 45.1 ± 13% for IVH (1 patient with ICH was excluded from analysis because of catheter breakage). There were no intracranial infections and no significant episodes of rebleeding according to clinical or CT assessment. One death occurred by 30 days after admission. Clinical improvements as determined by a decrease in the National Institutes of Health Stroke Scale score were demonstrated at 30 days after treatment in 7 of 9 patients. The rate of hemorrhage lysis was compared between 8 patients who completed treatment, and patient cohorts treated for IVH and ICH using identical doses of rt-PA and catheter drainage but without the ultrasound (courtesy of the MISTIE [Minimally Invasive Surgery plus T-PA for Intracerebral Hemorrhage Evacuation] and CLEAR II [Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage II] studies). Compared with the MISTIE and CLEAR data, the authors observed a faster rate of lysis during treatment for IVH and ICH in the patients treated with sonolysis plus rt-PA versus rt-PA alone.
Lysis and drainage of spontaneous ICH and IVH with a reduction in mass effect can be accomplished rapidly and safely through sonothrombolysis using stereotactically delivered drainage and ultrasound catheters via a bur hole. A larger clinical trial with catheters specifically designed for brain blood clot removal is warranted.
intracerebral hemorrhage; hypertensive hemorrhage; intraventricular hemorrhage; tissue plasminogen activator; ultrasound; sonothrombolysis
We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.
Vertebral artery; Dissection; Lateral medullary infarction
A gentleman, aged 54, with shunted hydrocephalus presented with recurrent chest infections. He had a ventriculoperitoneal (VP) shunt inserted when he was 38 years old for obstructive hydrocephalus due to a cerebellar tumour, with no subsequent shunt revisions since. Over a 2-year period, he presented with three episodes of pneumonia, which, on each occasion, responded well to antibiotics but then subsequently recurred. A chest x-ray identified the distal end of the VP shunt above the level of the diaphragm. CT scan found the distal end of the shunt tubing to be within a pulmonary bronchus. The VP shunt was revised and the patient had no subsequent recurrences of his chest infections. The authors review the complications of VP shunt placement including the more common sites of shunt tubing migration.
The aim of this study is to determine the association between the cerebrospinal fluid (CSF) biomarkers and inflammation, and the predictive value of these CSF biomarkers for subsequent shunt associated infection.
We obtained CSF samples from the patients with hydrocephalus during ventriculoperitoneal (VP) shunt operations. Twenty-two patients were enrolled for this study and divided into 3 groups: subarachnoid hemorrhage (SAH)-induced hydrocephalus, idiopathic normal pressure hydrocephalus (INPH) and hydrocephalus with a subsequent shunt infection. We analyzed the transforming growth factor-β1, tumor necrosis factor-α, vascular endothelial growth factor (VEGF) and total tau in the CSF by performing enzyme-linked immunosorbent assay. The subsequent development of shunt infection was confirmed by the clinical presentations, the CSF parameters and CSF culture from the shunt devices.
The mean VEGF concentration (±standard deviation) in the CSF of the SAH-induced hydrocephalus, INPH and shunt infection groups was 236±138, 237±80 and 627±391 pg/mL, respectively. There was a significant difference among the three groups (p=0.01). Between the SAH-induced hydrocephalus and infection groups and between the INPH and infection groups, there was a significant difference of the VEGF levels (p<0.01). However, the other marker levels did not differ among them.
The present study showed that only the CSF VEGF levels are associated with the subsequent development of shunt infection. Our results suggest that increased CSF VEGF could provide a good condition for bacteria that are introduced at the time of surgery to grow in the brain, rather than reflecting a sequel of bacterial infection before VP shunt.
Cerebrospinal fluid; Shunt infection; Biomarkers; Vascular endothelial growth factor; Hydrocephalus
It is well known that 10–15% of hydrocephalus cases at childhood and 40–50% in premature infants, occur following Germinal matrix hemorrhage (GMH). Such hemorrhages are reported to arise due to the rupture of germinal matrix (GM) vessels as a result of cerebral blod flow changes among infants with <1500 g birth weight and <32 weeks old. Intraventricular hemorrhage (IVH) associated with GMH leads to a disruption in the cerebrospinal fluid (CSF) and ventricular dilatation. Ventriculosubgaleal shunt (VSGS) is preferred in those hydrocephalus cases because it is a simple and rapid method, precludes the need for repetitive aspiration for evacuation of CSF, establishes a permanent decompression without causing electrolyte and nutritional losses, and aims to protect the cerebral development of newborns with GMH.
Material and method
The present study comprises 25 premature cases, subjected to VSGS and diagnosed with post-hemorrhagic hydrocephalus (PHH) arising from IVH associated with GM, and low birth weight (LBW) in the Neurosurgery Department of the Medical Faculty of Erciyes University between July 2002 and September 2006. VSGS surgery was performed on those cases, and their clinical and radiological prognoses were monitored with regard to several parameters.
Mortality and morbidity results were found to be lower than those in PPH treatment methods. While prognosis of grade 4 GMHs was poor, grades 2 and 3 GMHs displayed a much better prognosis after VSGS along with complete recovery in some hydrocephalus cases.
Germinal matrix hemorrhage; Hydrocephalus; Ventriculosubgaleal shunt
Congenital unilateral hydrocephalus is an uncommon entity occurring almost exclusively in children. Atresia, stenosis, membranous occlusion and even functional obstruction of the foramen of Monro have been described to be the main cause of this type of hydrocephalus. There are two options available in the surgical management of unilateral hydrocephalus: one is the placement of shunt CSF diversion from the dilated ventricle and the other is fenestration of the occluded foramen of Monro or septum pellucidum by endoscopy or by stereotactic method. Migration of the ventriculoperitoneal (VP) shunt in or out of ventricles is not so uncommon, but the relocation of the ventricular tip of a catheter from the ventricle into the quadrigeminal cisterns and superior vermis in association with ventriculostomy is extremely rare. Spontaneous ventriculostomy is a rare event and results from spontaneous rupture of a ventricle into the subarachnoid space.
A 5½-month-old baby with a right-sided congenital unilateral hydrocephalus underwent a VP shunt andhad experienced an uneventful outcome. Four years later on an MR imaging examination, the tip of the ventricular catheter passing through the medial wall of the ventricle and the quadrigeminal cistern was found to be situated in the superior vermis. During the follow-up period, there were no neurological difficulties. The cognitive and motor skill development corresponded well with the child's age. It transpired that the hydrocephalic ventricle reduced its size dramatically to normal.
We have described the extremely rare site of the relocation of the ventricular catheter after the treatment of the congenital unilateral hydrocephalus by VP shunting. Spontaneous ventriculostomy as a rare phenomenon may be the explanation of the relocation of the ventricular catheter.
Congenital unilateral hydrocephalus; ventriculoperitoneal shunt; ventriculostomy
Endoscopic third ventriculostomy (ETV) is a routine and safe procedure for therapy of obstructive hydrocephalus. The aim of our study is to evaluate ETV success rate in therapy of obstructive hydrocephalus in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. From 2001 till 2011, ETV was performed in 42 patients with former V-P drainage implantation. In all patients, the obstruction in aqueduct or outflow parts of the fourth ventricle was proved by MRI. During the surgery, V-P shunt was clipped and ETV was performed. In case of favourable clinical state and MRI functional stoma, the V-P shunt has been removed 3 months after ETV. These patients with V-P shunt possible removing were evaluated as successful. In our group of 42 patients we were successful in 29 patients (69%). There were two serious complications (4.7%)—one patient died 2.5 years and one patient died 1 year after surgery in consequence of delayed ETV failure. ETV is the method of choice in obstructive hydrocephalus even in patients with former V-P shunt implantation. In case of acute or scheduled V-P shunt surgical revision, MRI is feasible, and if ventricular system obstruction is diagnosed, the hydrocephalus may be solved endoscopically.
Patients with severe spontaneous cerebellar hemorrhage typically undergo treatment with suboccipital craniectomy and hematoma evacuation. However, this is a stressful procedure for patients due to the long operating time and operation-induced tissue damage. In addition, the durotomy can result in pseudomeningocele. We investigated the efficacy of stereotactic or navigation-guided burr hole aspiration surgery as a treatment for spontaneous hypertensive cerebellar hemorrhage (SHCH).
Between January 2002 and December 2011, 26 patients with SHCH underwent surgery using the stereotactic or navigation-guided burr hole aspiration and catheter insertion technique in our institution.
Mean hematoma volume was 21.8 ± 5.8 cc at admission and 13.1 ± 5.4 cc immediately following surgery. Preoperative Glasgow Coma Scale (GCS) score was 12.5 ± 1.3 and postoperative GCS score was 13.1 ± 1.2. Seven days after surgery, the mean hematoma volume was 4.3 ± 5.6 cc, and there was no occurrence of surgery-related complications during the six-month follow-up period. The mean operation time for catheter insertion was 43.1 ± 8.9 min, and a mean 31.3 ± 6.0 min was also added for extra-ventricular drainage. The mean Glasgow Outcome Scale (GOS) score after six months was 4.6 ± 1.0.
Stereotactic burr hole aspiration surgery for treatment of SHCH is less time-consuming and invasive than other interventions, and resulted in no surgery-related complications. Therefore, we suggest that this surgical method could be a safe and effective treatment option for selected patients with SHCH.
Cerebellar hemorrhage; Aspiration; Stereotactic; Navigation; Outcome
Endoscopic third ventriculostomy (ETV) is considered as a treatment of choice for obstructive hydrocephalus. It is indicated in hydrocephalus secondary to congenital aqueductal stenosis, posterior third ventricle tumor, cerebellar infarct, Dandy-Walker malformation, vein of Galen aneurism, syringomyelia with or without Chiari malformation type I, intraventricular hematoma, post infective, normal pressure hydrocephalus, myelomeningocele, multiloculated hydrocephalus, encephalocele, posterior fossa tumor and craniosynostosis. It is also indicated in block shunt or slit ventricle syndrome. Proper Pre-operative imaging for detailed assessment of the posterior communicating arteries distance from mid line, presence or absence of Liliequist membrane or other membranes, located in the prepontine cistern is useful. Measurement of lumbar elastance and resistance can predict patency of cranial subarachnoid space and complex hydrocephalus, which decides an ultimate outcome. Water jet dissection is an effective technique of ETV in thick floor. Ultrasonic contact probe can be useful in selected patients. Intra-operative ventriculo-stomography could help in confirming the adequacy of endoscopic procedure, thereby facilitating the need for shunt. Intraoperative observations of the patent aqueduct and prepontine cistern scarring are predictors of the risk of ETV failure. Such patients may be considered for shunt surgery. Magnetic resonance ventriculography and cine phase contrast magnetic resonance imaging are effective in assessing subarachnoid space and stoma patency after ETV. Proper case selection, post-operative care including monitoring of ICP and need for external ventricular drain, repeated lumbar puncture and CSF drainage, Ommaya reservoir in selected patients could help to increase success rate and reduce complications. Most of the complications develop in an early post-operative, but fatal complications can develop late which indicate an importance of long term follow up.
Cerebrospinal fluid shunt; endoscopy; endoscopic third ventriculostomy; hydrocephalus; neuroendoscpy; ventriculostomy
Acute transient obstructive hydrocephalus is rare in adults. We describe a patient with intraventricular hemorrhage (IVH) who experienced the delayed development of acute transient hydrocephalus.
A 33-year-old man with a previously diagnosed Spetzler-Martin Grade 5 arteriovenous malformation presented with severe headache, which was found to be due to IVH. Forty hours after presentation he developed significant obstructive hydrocephalus due to the thrombus migrating to the cerebral aqueduct, and a ventriculostomy placement was planned. However, shortly thereafter his headache began to improve spontaneously. Within 4 hours after onset the headache had completely resolved, and an interval head CT scan revealed resolution of hydrocephalus.
In patients with IVH, acute obstructive hydrocephalus can develop at any time after the ictus. Though a delayed presentation of acute but transient obstructive hydrocephalus is unusual, it is important to be aware of this scenario and ensure that deterioration secondary to thrombus migration and subsequent obstructive hydrocephalus do not occur.
acute hydrocephalus; intraventricular hemorrhage; arteriovenous malformation; transient hydrocephalus
Spontaneous intracerebral hemorrhage (ICH) is frequently associated with intraventricular hemorrhage (IVH), which is an independent predictor of poor outcome. The purpose of this study was to examine the relationship between ICH volume and anatomic location to IVH, and to determine if ICH decompression into the ventricle is truly beneficial.
We retrospectively analyzed the CT scans and charts of all patients with ICH admitted to our stroke center over a 3-year period. Outcome data were collected using our prospective stroke registry.
We identified 406 patients with ICH. A total of 45% had IVH. Thalamic and caudate locations had the highest IVH frequency (69% and 100%). ICH volume and ICH location were predictors of IVH (p < 0.001). Within each location, decompression ranges (specific volume ranges where ventricular rupture tends to occur) were established. Patients with IVH were twice as likely to have a poor outcome (discharge modified Rankin scale of 4 to 6) (OR 2.25, p = 0.001) when compared to patients without IVH. Caudate location was associated with a good outcome despite 100% incidence of IVH. Spontaneous ventricular decompression was not associated with better outcome, regardless of parenchymal volume reduction (p = 0.72).
Intraventricular hemorrhage (IVH) occurs in nearly half of patients with spontaneous intracerebral hemorrhage (ICH) and is related to ICH volume and location. IVH is likely to occur within the “decompression ranges” that take into account both ICH location and volume. Further, spontaneous ventricular decompression does not translate to better clinical outcome. This information may prove useful for future ICH trials, and to the clinician communicating with patients and families.
Brain temperature was measured at various depths beneath the
pial surface in patients with hydrocephalus of varying aetiology. Temperature increased gradually with depth in all patients, with the
highest temperature found in the ventricle. The difference between
intraventricular and rectal temperatures (Δv-r) was greater in
patients who underwent continuous ventricular drainage than in patients
who underwent ventriculoperitoneal shunt (continuous ventricular
drainage; 1.2 (SD 0.40)°C, mean (SD), n=5 v
ventriculoperitoneal shunt; 0.4 (SD 0.45)°C, n=16; p< 0.05). The
difference between intracerebral and rectal temperatures (Δb2-r) was
also greater in patients with continuous ventricular drainage than in
patients with ventriculoperitoneal shunt (continuous ventricular
drainage; 0.1 (SD 0.86)°C, n=5 v ventriculoperitoneal
shunt; −0.7 (0.86)°C, n=16; p< 0.05). Among patients with normal
pressure hydrocephalus, these differences were greater in the patients
with better outcomes after shunt surgery than in the less improved
group (Δv−r; 0.7(SD 0.27)°C, n=7 v 0.1 (SD
0.40)°C, n=5, p< 0.01, Δb2-r; −0.2 (SD 0.61)°C, n=7
v−1.4 (0.90)°C, n=5, p< 0.01).
In cases of pineal tumor combined with obstructive hydrocephalus, preoperative ventriculostomy or ventriculoperitoneal shunting is typically required prior to tumor resection. The objectives of preoperative ventriculostomy are gradual reduction of intracranial pressure and consequent preoperative brain protection. Here we report a case of pineal tumor resection with preoperative ventriculostomy that was complicated by multiple epidural hematomas. While postoperative intracranial hemorrhage may occur at any site, it is rare in those areas remote from the operative field. In the present case, multiple remote sequential epidural hematomas developed following resection of a pineal gland tumor. We also discuss the pathophysiologic mechanisms and provide a literature review.
Hydrocephalus; multiple epidural hematoma; pineal tumor
Ventriculoperitoneal shunt is the preferred treatment for hydrocephalus. Known complications include infection, obstruction, and disconnection with the fractured fragment migrating in the peritoneal cavity. We report 17 cases of laparoscopic evaluation and revision of ventriculoperitoneal shunts in children.
From January 2000 through October 2002, we retrospectively reviewed our experience with laparoscopy and ventriculoperitoneal shunts.
Laparoscopy was performed in 17 children with a malfunctioning shunt, presumed shunt dislodgment or disconnection, reinsertion of a shunt after externalization, and primary shunt placement. Six patients (35%) were converted to an open laparotomy due to dense adhesions. Eleven patients (65%) underwent successful laparoscopic-assisted ventriculoperitoneal shunt placement: 5/11 (45%) had lysis of adhesions or pseudocyst marsupialization with repositioning of a functional shunt, or both; 3/11 (27%) had successful retrieval of a disconnected catheter with reinsertion of a new catheter; 2/11 (18%) had laparoscopic confirmation of satisfactory placement and function, requiring no revision; 1/11 (9%) had an initial shunt placed with laparoscopic guidance due to the obesity. Operative time for the laparoscopic procedure ranged from 30 minutes to 60 minutes. All laparoscopic procedures used 1-mm or two 5-mm ports. Perioperatively, no adverse neurological sequelae occurred due to the pneumoperitoneum.
Laparoscopic guidance or revision of ventriculoperitoneal shunts permits (1) direct visualization of catheter insertion within the peritoneal cavity, (2) satisfactory positioning, (3) lysis of adhesions or marsupialization with catheter repositioning, or both, and (4) retrieval of fractured catheters.
Laparoscopy; Ventriculoperitoneal shunt; Children; Hydrocephalus
Between 2005 and 2010, we treated patients with hydrocephalus related to cerebral metastases, who were not good candidates for surgical resection by either endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS). Patients were excluded from ETV if they had a clinical history suggestive of non-obstructive hydrocephalus, including: (1) history of infection or ventricular hemorrhage and (2) leptomeningeal carcinomatosis. The rest of the patients were treated with VPS.
We analyzed the clinical outcome of these patient cohorts, to determine whether the efficacy of VPS was compromised due to a history of infection, ventricular hemorrhage, or leptomeningeal carcinomatosis, and compared these results to those patients who underwent ETV.
Sixteen patients were treated with ETV and 36 patients were treated with VPS. The overall efficacy of symptomatic palliation was comparable in the ETV and VPS patients (ETV = 69%, VPS = 75%). In both groups, patients with more severe hydrocephalic symptoms such as nausea, vomiting, and lethargy were more likely to benefit from the procedure. The overall complication rate for the two groups was comparable (ETV = 12.6%, VPS = 19.4%), although the spectrum of complications differed. The overall survival, initial Karnofsky performance status (KPS), and three-month KPS, were similarly comparable (median survival: ETV 3 months, VPS 5.5 months; initial KPS: ETV = 66 ± 7, VPS = 69 ± 12; 3 months KPS: ETV = 86 ± 7, KPS = 84 ± 12).
VPS remains a reasonable option for poor RPA grade metastasis patients with hydrocephalus, even in the setting of a previous infection, hemorrhage, or in those with leptomeningeal disease. Optimal treatment of this population will involve the judicious consideration of the relative merits of VPS and ETV.
Cerebral metastasis; endoscopic third ventriculostomy; palliation; Ventriculoperitoneal shunting
To hypothesize that detailed examination of early cerebellar volumes over time would distinguish differences in cerebellar growth associated with intraventricular hemorrhage (IVH) and white matter injury (WMI) in preterm infants.
Preterm newborns at the University of California San Francisco (n=57) and the University of British Columbia (n=115) were studied using serial MRI scans near birth and again at near term-equivalent age. Interactive semi-automated tools were used to determine volumes of the cerebellar hemispheres.
Adjusting for supratentorial brain injury, cerebellar hemorrhage, and study site, cerebellar volume increased 1.7cm3/week postmenstrual age (95% CI 1.6–1.7, P<0.001). More severe supratentorial IVH was associated with slower growth of cerebellar volumes (P<0.001). Volumes by 40 weeks were 1.4 cm3 lower in premature infants with grade 1–2 IVH and 5.4 cm3 lower with grade 3–4 IVH. The same magnitude of decrease was found between ipsilateral and contralateral IVH. No association was found with severity of WMI (P=0.3).
Early effects of decreased cerebellar volume associated with supratentorial IVH in either hemisphere may be a result of concurrent cerebellar injury or direct effects of subarachnoid blood on cerebellar development.
preterm; neuroimaging; cerebellum; intraventricular hemorrhage
Background. Subdural collections of cerebrospinal fluid (CSF) with associated hydrocephalus have been described by several different and sometimes inaccurate terms. It has been proposed that a subdural effusion with hydrocephalus (SDEH) can be treated effectively with a ventriculoperitoneal shunt (V-P shunt). In this study, we present our experience treating patients with SDEH without directly treating the subdural collection. Methods. We treated three patients with subdural effusions and hydrocephalus as a result of a head injury. All the patients were treated with a V-P shunt despite the fact that there was an extra-axial CSF collection with midline shift. Results. In all of the patients, the subdural effusions subsided and the ventricular dilatation improved in the postoperative period. The final clinical outcome remains difficult to predict and depends not only on the successful CSF diversion but also on the primary and secondary brain insult. Conclusion. Subdural effusions with hydrocephalus can be safely and effectively treated with V-P shunting, without directly treating the subdural effusion which subsides along with the treatment of hydrocephalus. However, it is extremely important to make an accurate diagnosis of an SDEH and differentiate this condition from other subdural collections which require different management.
We examined the cerebrospinal fluid (CSF) markers of subarachnoid hemorrhage (SAH)-induced and idiopathic normal pressure hydrocephalus (INPH) to investigate the pathophysiology and mechanism of communicating hydrocephalus compared to obstructive hydrocephalus.
We obtained CSF samples from 8 INPH, 10 SAH-induced hydrocephalus, and 6 unmatched patients with non-hemorrhagic obstructive hydrocephalus during their ventriculoperitoneal shunt operations. Transforming growth factor (TGF)-β1, tumor necrosis factor (TNF)-α, vascular endothelial growth factor (VEGF), and total tau in the CSF were analyzed via enzyme-linked immunosorbent assay.
The mean VEGF levels in the CSF of patients with SAH-induced hydrocephalus, INPH, and obstructive hydrocephalus were 239±131, 239±75, and 163±122 pg/mL, respectively. The total tau concentrations in the CSF of the groups were 1139±1900, 325±325, and 1550±2886 pg/mL, respectively. TNF-α values were 114±34, 134±38, and 55±16 pg/mL, respectively. TGF-β1 values were 953±430, 869±447, and 136±63 pg/mL, respectively. A significant difference in TNF-α and TGF-β1 levels was observed only between SAH-induced and chronic obstructive hydrocephalus, and between INPH and chronic obstructive hydrocephalus (p<0.01).
No significant differences in the 4 CSF biomarker levels were observed between INPH and SAH-induced hydrocephalus, whereas CSF TNF-α and TGF-β1 levels were increased compared to those in patients with chronic obstructive hydrocephalus. Post-SAH hydrocephalus and INPH are probably more destructive to neural tissues, and then stimulate the inflammatory reaction and healing process, compared with obstructive hydrocephalus.
cerebrospinal fluid; subarachnoid hemorrhage; normal pressure hydrocephalus; transforming growth factor-β1; tumor necrosis factor-α; vascular endothelial growth factor; total tau