Trigeminal palsy caused by triventricular hydrocephalus. A case report

A case of left trigeminal palsy caused by triventricular hydrocephalus and completely recovered after ventriculo peritoneal shunt is reported. The case was studied by MR before and after the operation. Preoperative MR showed triventricular hydrocephalus with marked reduction of the left Meckel's cave. Following ventriculo peritoneal shunt the patient showed a complete recovery of the left 5th nerve palsy and NR showed the expansion of the left Meckel's cave. The authors suggest that the trigeminal palsy was due to intracranial hypertension probably associated to a weakness of the lateral wall of the left Meckel's cave. No similar case have been previously reported in the literature.     

Management of intraventricular haemorrhage in patients with haemorrhagic cerebrovascular diseases

The authors propose a four-grade classification for intraventricular haemorrhage (IVH) caused by haemorrhagic cerebrovascular diseases. Grading is based on the distribution and volume of the haematoma in the ventricular system as revealed by computed tomography (CT). In Grade I IVH, CT shows no haematoma in the ventricular system, but the cerebrospinal fluid contains some fresh blood; Grade II IVH fills a circumscribed portion of one or both lateral ventricles. This grade is divided into two: Grade IIa having a haematoma volume of, or less than 20 ml in the ventricular system and Grade IIb of more than 21 ml; Grade III IVH fills the entire length of one lateral ventricle and none, or circumscribed portion, of the other lateral ventricle; and Grade IV IVH entirely fills both lateral ventricles. This grading scale correlated with the mortality and morbidity of the IVH patients. Its application will assist in the selection of continuous ventricular drainage or direct evacuation of intraventricular haematoma as the management method.     

Clinical study on developmental hydrocephalus and its operative timing in lumbo-sacral meningomyelocele

Nine infants with lumbo-sacral meningomyelocele were evaluated in the diagnosis and the operative timing of hydrocephalus. Seven cases received early operation for meningomyelocele within 36 hours after birth. Two cases with closed meningomyelocele were operated on 8 days and 32 days after birth. All of them were not infected in the central nervous system before and after its surgery. Five out of nine cases had rapidly developed hydrocephalus within a few weeks, and received ventriculo-peritoneal shunt (Shunt group: Case1-5). Two cases with gradual enlargement of the lateral ventricles and two cases with normal development have been observed without shunt procedure (Non-shunt group: Case 6-9). The authors recorded the head circumference, Evans' index on CT, and intracranial pressure of those infants at birth and following days. The head circumference at birth was almost within a normal size in both groups. On the other hand, an average of Evans' index in shunt group at birth was greater than that of non-shunt group. Moreover, the growth rate of head circumference and lateral ventricle of shunt group were more markedly increased than that of non-shunt group. The head circumference and the ventriculomegaly on a computed tomography at birth were poor prediction of hydrocephalus, however, there was positive correlation between the rate of head growth and the rate of hydrocephalic development. That is to say, the growth rate of a head circumference and growth of Evans' index suggested the prediction of a progressing hydrocephalus during the first few weeks.     

A case of aqueductal stenosis with acute progressive hydrocephalus during pregnancy

The authors present a case of aqueductal stenosis (AS) with acute progressive symptoms during pregnancy. A 39-year-old pregnant woman in 19th gestation week was admitted with headache, nausea and deterioration of consciousness. On admission, computed tomography (CT) scan showed acute hydrocephalus. Ventricular drainage was performed on emergency and her symptoms were resolved in a few days. Postoperative T2-weighted MR images showed enlargement of the lateral and third ventricles with membranous occlusion of the aqueduct. Endoscopic third ventriculostomy was performed uneventfully. A healthy baby was delivered by Cesarean section in 36th gestation week considering her previous extirpation of hysteromyoma. In this case of pregnant woman, increase of total body water, cardiac output, and central venous pressure, and decrease in plasma osmotic pressure might contribute to development and sudden worsing of symptoms of pre-existed hydrocephalus due to aqueductal stenosis. Endoscopic third ventriculostomy, especially in the pregnant case, should be recommended in hydrocephalus due to aqueductal stenosis to avoid shunt malfunction caused by increasing intraabdominal pressure and shunt infecton during Cesarean section.     

Clinical value of bedside ultrasonography in craniectomized patients

Twenty-five patients underwent bedside ultrasonographic examination through a postoperative skull defect, and the images were compared with axial computed tomography (CT) scans. The patients included 12 with cerebrovascular disease, two with brain tumor, one with a brain abscess, and 10 with head injury. Clear ultrasonographic images were obtained in all patients except one who had undergone a suboccipital craniectomy. Ultrasound was most useful when hydrocephalus was present, in which cases, regardless of the cause, hypo-echoic dilated third and lateral ventricles were demonstrated. In one case, it was decided to emplace a ventriculoperitoneal shunt on the basis of the results of serial sonography, which documented ventricular enlargement. Intracerebral hematomas also were identified by ultrasonography. Acute hematomas, such as subarachnoid blood clots persisting after clipping of an aneurysm, appeared as hyper-echoic images, whereas, late hematomas were depicted as hypo-echoic images. In one case, a recurrent brain tumor was depicted as a hyper-echoic mass. In multiple-trauma patients with head injury who were too unstable to be moved for CT scanning, ultrasound was extremely useful. So-called "delayed traumatic intracerebral hematoma" was identified in two cases subsequent to removal of an acute subdural hematoma. These results that serial ultrasonographic examination of the lateral ventricles through a craniectomy can supplement CT scanning in the evaluation of hydrocephalus and is also useful in evaluating cerebrovascular disease, brain tumors, infection, and head injury.     

Cauda equina neurinoma associated with normal pressure hydrocephalus--case report.

A 45-year-old male was hospitalized because of gait disturbance, urinary incontinence, and memory disturbance. A computed tomographic (CT) scan revealed dilatation of the cerebral ventricles, and a metrizamide CT scan showed reflux into all ventricles. Cerebrospinal fluid obtained at the time of metrizamide CT was highly xanthochromic. Myelograms demonstrated a tumor between the inferior portion of the fifth lumbar vertebra and that of the second sacral vertebra. After removal of a spinal tumor involving nerve fibers at the cauda equina, his symptoms disappeared and the spinal fluid protein normalized. Three months after surgery, a CT scan revealed reduction of cerebral ventricular size. There are 10 reported cases of spinal tumors resulting in normal pressure hydrocephalus. All these and present cases involved protein in the spinal fluid, which might have been the cause of the hydrocephalus.     

Intraventricular cryptococcal granulomas--case report

A 54-year-old, previously healthy female with chronic meningocencephalitis is presented. Computed tomography (CT) revealed hydrocephalus and mass lesions in both the lateral and fourth ventricles. A culture of cerebrospinal fluid obtained from the lateral ventricle on admission was negative, but 2 years later, when the meningoencephalitis recurred, Cryptococcus neoformans was cultured. The diagnostic difficulties and CT features of intracranial cryptococcal granulomas are discussed.     

A new ventriculocisternal shunt technique in treatment of noncommunicating hydrocephalus: A technical note with a brief discussion of the literature

Summary Ventriculo-cisternostomy is an established procedure for the treatment of noncommunicating hydrocephalus, if the underlying pathology cannot be removed.In cases in which the foramina of Monro and the proximal part of the third ventricle are obstructed, it is not possible to make a communication between the internal and external CSF-spaces by perforation of the floor of the third ventricle, the so-called third ventriculo-cisternostomy.For such cases the authors describe a new method of drainage of both lateral ventricles to the interpeduncular cistern. This new method has been used successfully in a case with obstructive hydrocephalus of both lateral ventricles, caused by a pilocytic astrocytoma of the optic chiasma and hypothalamus with obstruction of both foramina of Monro.     

Third ventricular cysts and membranes unsuspected on conventional CT and MRI

Three cases are presented of symptomatic cysts or membranes within the third ventricle interfering with CSF flow and presenting as non-communicating triventricular hydrocephalus. None was visible on conventional CT or MRI, two being discovered at neuroendoscopy and one only with a specific MRI sequence designed to show CSF partitioning.     

Endoscopic third ventriculostomy for hydrocephalus.

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.     

Isolated ventricles following intraventricular hemorrhage

Panventricular enlargement often follows intraventricular hemorrhage in the premature neonate. During a recent 12-month period, the authors identified five infants who required shunting because of symptomatic post-hemorrhagic hydrocephalus, which was progressive despite serial lumbar punctures and the use of indwelling subcutaneous ventricular reservoirs. In the first 6 months following placement of the initial shunt, four of the infants required an additional shunt for isolated ventricles. Two children had isolation of the lateral ventricles and required bilateral shunts. Two other children had isolation of the fourth ventricle from the lateral ventricular system and required posterior fossa shunts. All of the children were treated successfully using multiple shunts. In all cases, progressive dilation of the isolated ventricle was unaccompanied by the usual clinical signs of shunt malfunction. It appears that isolated ventricular systems are common following post-hemorrhagic hydrocephalus and these children must be followed closely with ultrasound and computerized tomography scanning.     

Surgical removal of bilateral papillomas of the choroid plexus of the lateral ventricles with resolution of hydrocephalus. Case report.

The authors report a patient with bilateral papillomas of the choroid plexus of the lateral ventricles with documentation of cerebrospinal fluid (CSF) hypersecretion causing hydrocephalus. Special attention is given to the large volume of CSF produced by these tumors (removal of one tumor reduced CSF outflow by one-half) and to the fact that CSF diversion was not required after both tumors were removed. Since tumor removal alone was sufficient to stop the progression of hydrocephalus, we feel that this case supports the concept that elevated CSF production by itself is sufficient to cause hydrocephalus in patients with papillomas of the choroid plexus.     

Trapped Third Ventricle

Summary  The authors report the case of a 29-year-old female who presented with symptoms of shunt dysfunction 11 years after first being shunted for an aqueductal stenosis. After numerous revisions she developed an isolated third ventricle, necessitating triventricular shunting to obtain a new equilibrium. An isolated third ventricle is a very rare phenomenon, usually seen in very complex hydrocephalus and only reported on twice before (Filler et al., 1995). Etiological factors postulated in the development of an isolated lateral or fourth ventricle, all seem to contribute also to the development of an isolated third ventricle.     

Fenestration of intraventricular cysts using a flexible, steerable endoscope and the argon laser

Two infants with hydrocephalus and compartmentalization of the lateral ventricles due to cerebrospinal fluid infection were treated by fenestration of the ventricular cysts using the argon laser through a steerable flexible endoscope. Both children had undergone failed multiple shunting procedures that attempted to drain the lateral ventricular cysts. One child had chronic granulomatous disease and persistent Candida ventriculitis and meningitis. His infection resolved after removal of multiple shunt systems was made possible by endoscopic laser fenestration to convert a multilocular to a unilocular hydrocephalus. Postoperative computed tomographic scans and head circumference measurements showed arrested hydrocephalus in both cases, and both children remain symptom-free 6 months after operation. The argon laser was used to coagulate and incise the ventricular septae in both cases. The steerable flexible endoscope enabled excellent visualization of the ventricular system without manipulation of the endoscope at the corticotomy site. Necessary improvements in the design of the flexible endoscope and the delivery system for the argon laser are discussed.     

Large encephalocele at the anterior fontanel--case report

The authors report a newborn girl with a large meningoencephalocele, 18.5 cm in diameter, at the anterior fontanel. She had several accompanying anomalies, including microcephalus, cleft palate, and a uvula bifida. A plain skull x-ray revealed craniolacunia and a computed tomography (CT) scan showed maldevelopment of the cerebrum. The mass was resected, after which the fontanel was noted to bulge. CT demonstrated dilated lateral ventricles. A successful shunting procedure permitted the infant to leave the hospital in good general condition.     

Cisterna megamagna. Dimensions and relations to cerebral atrophy. Clinical and x-ray computed tomographic demonstration

Polaroids of 9,400 consecutive unselected computed tomography (CT) scans are reviewed and 31 cases with Mega Cisterna Magna (MCM) are detected. The incidence is 0.33% (31/9,400). Clinical and radiological data relating to these 31 cases shows that none of the patients presented neither any clinical sign of a posterior fossa space occupying lesion nor any radiological image such as hydrocephalus or forward displacement of the fourth ventricle. The dimensions of the cistern ranged as follows: width between 22.2-92.5 mm, depth between 22.2-37.0 mm, height between 26.0-39.0 mm. The authors propose 20 mm as the limit value of width and depth of a normal cisterna magna and 26 mm for its maximal height, these dimensions being the most frequently encountered ones of these 31 patients. The correlation between the magnitude of the cistern (the sum of the width and depth of the cistern: w + d) and the severity of cerebral atrophy (the sum of the maximum and minimum widths of the anterior horns of the lateral ventricles which is the most reliable atrophy index defined by Hirashima: a + b) is illustrated in figure 5. The authors conclude that Mega Cisterna Magna which has a constant incidence in routine CT examinations is predominantly a consequence of cerebral atrophy and does not have any specific clinical pathological correlate and does not require any form of treatment.     

The trapped temporal horn: a trap in neuroradiological diagnosis.

Although the advent of computerized cranial tomography (CT) has decreased the number of pneumoencephalograms performed for the diagnosis of hydrocephalus and lesions of the posterior fossa, brain stem, and ventricles, there are some patients in whom pneumoencephalography should still be done because it adds valuable information to that obtained with CT. When the temporal horn becomes obstructed, the choroid plexus and ependymal surface "upstream" from the obstructing mass continue to produce cerebrospinal fluid (CSF). The temporal horn can thus enlarge enough to appear as a mass on CT because of its reduced x-ray attenuation coefficient. Pneumoencephalography is effective in this situation because air will flow past a mass that obstructs CSF and because the ventricular system dilates during pneumoencephalography. When pneumoencephalography is used in a patient with a trapped temporal horn, the partially trapped horn may enlarge approximately 24 hours later. With that precaution in mind, the neurosurgeon should find pneumoencephalography to be a useful adjunct to CT in delineating the cause of a trapped temporal horn. In the three patients reported here CT had indicated a unilateral trapped temporal horn; pneumoencephalography confirmed that finding and demonstrated both the location and the nature of the lesion. One patient had a Grade II astrocytoma fungating into the atrium of the right lateral ventricle, one had a mass extending into the right ventricle from the medial and superior ventricular wall with nodular encroachment on the ventricle, and one had a meningioma in the atrium of the right lateral ventricle.     

A case of quadrigeminal cistern arachnoid cyst associated with hydrocephalus

A case of quadrigeminal cistern arachnoid cyst associated with hydrocephalus is reported. A 1-year-old girl was admitted to our service on July 31, 1984, because of mental retardation and an enlarged head. She was born of a full-term pregnancy and normal vaginal delivery without prenatal complications. Progressive increase in her head circumference was noticed at the age of 6 months by her family physician. On admission she was found to be a well-nourished infant with a head circumference of 56 cm, bulging anterior fontanelle and mental retardation. Marked dilatation of the lateral ventricles and a large cyst in the quadrigeminal cistern were demonstrated on plain CT. There were no findings of communication between the ventricular system and the cyst on metrizamide CT ventriculography. The extension of the cyst from the quadrigeminal cistern to the right cerebello-pontine angle was demonstrated on reconstructed coronal CT. Reconstructed sagittal section revealed huge hydrocephalus caused by aqueductal stenosis. A vertebral angiography demonstrated opening of the para-mesencephalic segments of the bilateral posterior cerebral arteries and downward displacement of the right superior cerebellar artery. Accordingly, a large quadrigeminal cistern arachnoid cyst with hydrocephalus caused by aqueductal stenosis was suspected. Following V-P shunt operation for hydrocephalus, right temporo-parietal craniotomy was performed. The inner wall of the lateral ventricle was thin and an expanding cyst was observed through it. A partial resection of the cyst wall with the ventricular wall was performed to obtain communication between the cyst and lateral ventricle. The content of the cyst was watery clear fluid like CSF.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraventricular hemorrhage in blunt head trauma: an analysis of 43 cases.

Before the advent of computed tomography, intraventricular hemorrhage (IVH) from any source was thought rare and invariably fatal. Although intraventricular blood is readily identifiable with computed tomography, there has been little systematic study of its significance in blunt head trauma. Forty-three patients with traumatic IVH were prospectively identified in 1 year at Harborview Medical Center (University of Washington). Most were victims of motor vehicle accidents and suffered severe head injuries. IVH occurred alone in two patients; superficial contusions and subarachnoid hemorrhage were the most common associated finding. Blood was present in only one or both lateral ventricles in 25 patients; only the 3rd or 4th ventricles in 4 and all ventricles in 14 instances. There were 3 intracerebral hematomas and 14 basal ganglion hemorrhages. All of the former and half of the latter communicated with the adjacent lateral ventricle. Extra-axial hematomas appeared more common when only the lateral ventricles were involved, whereas corpus callosum or brain-stem hemorrhage appeared more likely when all the ventricles were involved. Acute hydrocephalus was rare, and ventricular drainage was needed in only four cases. Intracranial pressure (ICP) was elevated (> 15 mm Hg) in 46% of patients. The amount of IVH was related inversely with the Glasgow Coma Scale, but not with increased ICP. The presence of IVH indicated a poor outcome, with only half of the patients being independent at a 6-month follow-up. Poor outcome was associated with increasing age, low admission Glasgow Coma Scale, the presence of space occupying lesions if only the lateral ventricles were involved, and hemorrhage in all four ventricles.(ABSTRACT TRUNCATED AT 250 WORDS)