Surgery of hydrocephalus: past,present and future

Summary The treatment of hydrocephalus, over the centuries, underwent three stages of evolution.During antiquity, middle ages and Renaissance, hydrocephalus was not understood. Medical treatment was useless; surgery was hopeless.The second stage extends from the XIXth century to the end of the first half of the XXth century. CSF circulation was now understood; surgery however, remained inefficient, but some patients survived with arrested hydrocephalus.The third stage begins in the nineteen fifties with the development of silicone shunts with a valve. Surgery transforms the prognosis of hydrocephalus, but the number of post-operative complications creates new problems. The different attempts that have been made during these past two decades to solve these problems are reviewed. They have resulted in a reduction of the mechanical and infectious complications. CSF overdrainage has been minimized. Percutaneous ventriculocisternostomies have in some cases replaced shunts.In the future, to improve outcome in these hydrocephalics, surgery, when indicated, should be performed as early as possible. Knowledge and prevention of the causes of hydrocephalus should be developed.Invited Lecture, presented at the European Congress of Neurosurgery, Moscow, June 23–29, 1991.     

Ventriculocholecysto shunt: a solution to recurrent shunt complications in comorbid post-tubercular hydrocephalus with tubercular adhesive peritonitis

Background

Tuberculosis is still a killer disease and a nightmare in developing countries. Post-tubercular hydrocephalus remains one of the most severe complications, with many diversion procedure methods. How common is the occurrence of co-morbid post tubercular hydrocephalus with tubercular peritonitis is still not known. This is a frustrating cause of repeated shunt complications and revisions.

Methods

We discuss the management of two cases that were the cause of nearly 50 % of our shunt revisions due to the comorbidities of post-tubercular hydrocephalus and tubercular adhesive peritonitis. We performed the ventriculocholecysto (VC) shunt. This procedure diverts CSF from the ventricular system to the gall bladder.

Results

The two children are disease free and did not require a revision in the 3.4-year follow-up period.

Conclusion

The VC shunt is a simple procedure. It improved the quality of life of these children who otherwise would have had a very morbid period during shunt revisions and the active disease. These children did not require further revisions and can grow normally.     

Ventricular subarachnoidal hydrocephalus of arachnoid villi origin

In 102 infants (0.5 to 22 months), the C.T. scan performed for various neurological symptoms, was systematically reviewed with analysis of ventricular size, pericerebral space and interhemispheric fissure. In 70% of the cases, an increase of the intracranial volume of C.S.F. was noted, with a good correlation between the ventricular and pericerebral volume. The authors discuss the pathophysiological mechanism of this condition an evoke the possibility of an idiopathic disturbance of the C.S.F. reabsorption. In two cases, suffering from severe axial hypotonus, this fact was explored by four methods: continuous monitoring of intracranial pressure, intraventricular infusion test, isotopic cisternography through ventricular injection and venous phase of angiography. From these investigations showing no venous anomaly, and because of the lack of any pathological event able to induce a C.S.F. obstruction, we suggest a delay in the maturation of arachno?d villi (normally ended at 18 months) to explain this condition.     

Surgical management of adult hydrocephalus

The management of adult hydrocephalus spans a broad range of disorders and ages. Modern management strategies include endoscopic and adjustable cerebrospinal fluid shunt diversionary techniques. The assessment and management of the following clinical conditions are discussed: 1) the adult patient with congenital or childhood-onset hydrocephalus, 2) adult slit ventricle syndrome, 3) multicompartmental hydrocephalus, 4) noncommunicating hydrocephalus, 5) communicating hydrocephalus, 6) normal pressure hydrocephalus, and 7) the shunted patient with headaches. The hydrodynamics of cerebrospinal fluid shunt diversion are discussed in relation to mechanisms of under- and overdrainage conditions. A rationale for the routine implementation of adjustable valves for adult patients with hydrocephalus is provided based on objective clinical and experimental data. For the condition of normal pressure hydrocephalus, recommendations are offered regarding the evaluation, surgical treatment, and postoperative management of this disorder.     

Case report: tubercular cold abscess of seminal vesicle: minimally invasive endoscopic management

BACKGROUND: Tubercular cold abscess of the seminal vesicle is very rare, and only a few cases are reported in literature. Preoperative diagnosis is difficult and to the best of our knowledge has not been reported. CASE REPORT: A 35-year-old man presented with a 7-year history of blood in the semen and a reddish brownish discharge per urethra while defecating. On rectal examination, a soft fluctuant mass was felt above the prostate. Abdominal ultrasonography showed cystic swelling of the right seminal vesicle bulging into the posterior bladder wall. Semen examination showed abundant pus cells and 90% immotile sperm with normal morphology. Acid-fast bacilli were not seen, but acid-fast bacilli were found in a 24-hour urine specimen. Cystoscopy showed tubercles in the urethra and brownish discharge from the orifice of the right ejaculatory duct on per-rectal compression of the mass. The abscess cavity was incised with a Collings' knife. Brownish material was evacuated, and the abscess cavity was seen. An 18F Foley catheter was placed for 3 days. Antitubercular therapy was instituted. Ultrasonography repeated after 3, 25, 45, and 75 days showed gradual regression of the abscess cavity. Semen examination after 75 days was normal, with 75% motility, and cystoscopy 45 days postoperatively showed complete healing of the wound. CONCLUSION: The incision connecting the bladder with the abscess cavity facilitated evacuation of pus and complete resolution of the abscess.     

Systemic autoimmune diseases complicated with hydrocephalus: pathogenesis and management

Neurosurgical Review - Systemic autoimmune diseases (SAIDs) represent a group of syndromes involving at least two organ systems. Classical SAIDs include connective tissue diseases, vasculitis, and...     

The surgical management of pediatric hydrocephalus

The surgical management of hydrocephalus has undergone incredible changes over the past generation of neurosurgeons, including dramatic improvements in imaging, especially computed tomographic scanning and magnetic resonance imaging, and remarkably innovative advances in cerebrospinal fluid valve technology, complex computer models, and endoscopic equipment and techniques. In terms of overall patient outcomes, however, one could conclude that things are a little better, but "not much." This frustrating yet fascinating dichotomy between technological advancements and clinical outcomes makes hydrocephalus, first described by the ancients, as one of the most understated and complex disorders that neurosurgeons treat. The challenge to the next generation of neurosurgeons is to solve this vexing problem through better understanding of the basic science, improved computer models, additional technological advances, and, most importantly, a broad-based, concerted multidisciplinary attack on this disorder. This review focuses on the evolution of surgery for hydrocephalus over the last 30 years, the current state of the art of hydrocephalus treatment, and what appear to be the most promising future directions.     

Antenatal oligohydramnios of renal origin: postnatal therapeutic and prognostic challenges.

Urinary tract anomalies (UTA) including polycystic kidney disease nowadays can be detected antenatally by ultrasound. The concomitant presence of oligohydramnios has been regarded as a severe risk factor for renal dysfunction and pulmonary hypoplasia, although clinical data after birth are scarce. We report the postnatal course and long-term follow-up of 10 infants with oligohydramnios due to congenital UTA from two pediatric nephrology centers. The underlying final diagnoses were autosomal-recessive polycystic kidney disease (ARPKD, n = 2), familial tubular dysgenesis (n = 2) and bilateral renal hypoplasia (n = 6) including 3 children with posterior urethral valves. Two children died in the neonatal period while 8 children are currently alive at a median age of 2.5 (range 1.1-10) years. In the postnatal period, respiratory failure necessitating mechanical ventilation occurred in 7 infants (including the 2 non-survivors). All surviving children had chronic renal failure, which could be managed conservatively in 6 children (median GFR 45 (range 15-53) ml/min/1.73 m2) while 2 reached end-stage renal disease; one undergoing preemptive kidney transplantation and one peritoneal dialysis. Seven of 8 children reached normal developmental milestones. In conclusion, the presence of antenatal oligohydramnios in infants with UTA does not always carry a poor prognosis. The high incidence of perinatal complications, the complexity of underlying causes and the prevalence of postnatal chronic renal dysfunction calls for a multidisciplinary approach in the management of these children.     

Paraganglioma of the mediastinum: challenges in diagnosis and surgical management

Mediastinal paraganglioms are rare, highly vascularized tumors arising from chromaffin tissue located in the para-aortic ganglia. Tumors tend to invade bordering structures and may also form metastasis. Up to 50% of patients are asymptomatic and diagnosis is incidental. Presenting symptoms are related to catecholamine hypersecretion or to a mass effect. Complete surgical resection remains the standard of care due to malignant potential of the tumor and poor response to chemotherapy or radiation. Strategic location of the tumor in proximity to great vessels, trachea, and recurrent laryngeal nerve poses challenge for the surgeon. We report a case of a 59-year old asymptomatic female who was incidentally diagnosed with a middle mediastinal mass on a positron-emission tomography (PET-CT) scan performed as part of breast cancer surveillance. Complete resection of the tumor was achieved using cardiopulmonary bypass. The patient recovered uneventfully and in a ten-month follow up there is no evidence of recurrence.     

Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients

OBJECT: The diagnosis and management of idiopathic normal-pressure hydrocephalus (NPH) remains controversial, particularly in selecting patients for shunt insertion. The use of clinical criteria coupled with imaging studies has limited effectiveness in predicting shunt success. The goal of this prospective study was to assess the usefulness of clinical criteria together with brain imaging studies, resistance testing, and external lumbar drainage (ELD) of cerebrospinal fluid (CSF) in determining which patients would most likely benefit from shunt surgery. METHODS: One hundred fifty-one patients considered at risk for idiopathic NPH were prospectively studied according to a fixed management protocol. The clinical criterion for idiopathic NPH included ventriculomegaly demonstrated on computerized tomography or magnetic resonance imaging studies combined with gait disturbance, incontinence, and dementia. Subsequently, all patients with a clinical diagnosis of idiopathic NPH underwent a lumbar tap for the measurement of CSF resistance. Following this procedure, patients were admitted to the hospital neurosurgical service for a 3-day ELD of CSF. Video assessment of gait and neuropsychological testing was conducted before and after drainage. A shunt procedure was then offered to patients who had experienced clinical improvement from ELD. Shunt outcome was assessed at 1 year postsurgery. CONCLUSIONS: Data in this report affirm that gait improvement immediately following ELD is the best prognostic indicator of a positive shunt outcome, with an accuracy of prediction greater than 90%. Furthermore, bolus resistance testing is useful as a prognostic tool, does not require hospitalization, can be performed in an outpatient setting, and has an overall accuracy of 72% in predicting successful ELD outcome. Equally important is the finding that improvement with shunt surgery is independent of age up to the ninth decade of life in patients who improved on ELD.     

Case study: challenges of pessary management.

Genital prolapse is the relaxation of the supporting structures of the pelvic floor. Significant morbidity can be associated if left untreated. Patients can elect to have surgical repair of their prolapse or use a pessary. The more significant the pelvic organ prolapse the more difficult it is to manage with pessary support. The case study in this article describes such a patient and the challenges we faced with managing her advanced genital prolapse.     

Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analysis

OBJECT: The purpose of this paper is to elucidate the safety and efficacy of, and indications and outcome prognosis for endoscopic third ventriculostomy (ETV) in 58 patients with obstructive hydrocephalus. METHODS: Between September 1999 and April 2003, 58 ETVs were performed in 58 patients with obstructive hydrocephalus (36 male and 22 female patients) at the authors' institution. The ages of the patients ranged from 5 to 67 years (mean age 35 years) and the follow-up period ranged from 3 to 41 months (mean duration of follow up 24 months). Patients were divided into four subgroups based on the cause of the obstructive hydrocephalus: 21 with intracranial tumors; 11 with intracranial cysts; 18 with aqueductal stenosis: and eight with intracranial hemorrhage or infection. Both univariate and multivariate statistical analyses were performed to assess the prognostic relevance of the cause of the obstructive hydrocephalus, early postoperative clinical appearance, and neuroimaging findings in predicting the result of the ETV. The survival rate was 87% at the end of the 1st year and 84% at the end of the 2nd year post-ETV. One month after ETV an overall clinical improvement was observed in 45 (77.6%) of 58 patients. If we also consider the successful revision of ETV in two patients, a success rate of 78.3% (47 of 60 patients) was reached. The ETV was successful in 17 (81%) of 21 patients with intracranial tumors, nine (82%) of 11 with cystic lesions, 16 (88.9%) of 18 with aqueductal stenosis, and three (38%) of eight with intracranial hemorrhage or infection. A Kaplan-Meier analysis illustrates that the percentage of functioning ETVs stabilizes between 75 and 80% 1 year after the operation. In a comparison of results 1 year after ETV, the authors found that the aqueductal stenosis subgroup had the highest proportion of functioning ETV (89%). The proportions of the tumor and cyst subgroups were 84 and 82%, respectively, whereas the proportion was only 50% in the ventriculitis/intracranial hemorrhage subgroup (strata log-rank test: chi2 = 7.93, p = 0.0475). In the present study, ETV failed in eight patients (13.8%) and the time to failure after the procedure was a mean of 3.4 months (median 2 months, range 0-8 months). The logistic regression analysis confirmed an early postoperative improvement (within 2 weeks after ETV, significance [Sig] of log likelihood ratio [LLR] < 0.0001) and a patent stoma on cine phase-contrast magnetic resonance (MR) images (Sig of LLR = 0.0002) were significant prognostic factors for a successful ETV. The results demonstrated the multivariate model (B = -53.7309, standard error = 325.1732, Wald = 0.0273, Sig = 0.8688) could predict a correct result in terms of success or failure from ETV surgery in 89.66% of observed cases. The Pearson chi-square test demonstrated that little reliance could be placed on the finding of a reduced size of the lateral ventricle (chi2 = 5.305, p = 0.07) on neuroimaging studies within 2 weeks after ETV, but it became a significant predictive factor at 3 months (chi2 = 8.992, p = 0.011) and 6 months (chi2 = 10.586, p = 0.005) post-ETV. Major complications occurred in seven patients (12.1%), including intraoperative venous bleeding in three, arterial bleeding in one, and occlusion of the stoma in three patients. The overall mortality rate was 10.3% (six patients). One of these patients died of pulmonary infection and another of ventriculitis. Four additional patients died of progression of malignant tumor during the follow-up period. CONCLUSIONS: The results indicate that ETV is a most effective treatment in cases of obstructive hydrocephalus that is caused by aqueductal stenosis and space-occupying lesions. For patients with infections or intraventricular bleeding, ETV has considerable effects in selected cases with confirmed CSF dynamic studies. Early clinical and cine phase-contrast MR imaging findings after the operation play an important role in predicting patient outcomes after ETV. The predictive value of an alteration in ventricle size, especially during the early stage following ETV, is unsatisfactory. Seventy-five percent of ETV failures occur within 6 months after surgery. A repeated ventriculostomy should be considered to be a sufficient treatment option in cases in which stoma dysfunction is suspected.     

Issues and challenges in diabetic neuropathy management: A narrative review

Diabetic neuropathy (DN) is a devastating disorder with an increasing prevalence globally. This epidemic can pose a critical burden on individuals and com-munities, subsequently affecting the productivity and economic output of a country. With more people living a sedentary lifestyle, the incidence of DN is escalating worldwide. Many researchers have relentlessly worked on ways to combat this devastating disease. Their efforts have given rise to a number of commercially available therapies that can alleviate the symptoms of DN. Unfortunately, most of these therapies are only partially effective. Worse still, some are associated with unfavorable side effects. This narrative review aims to highlight current issues and challenges in the management of DN, especially from the perspective of molecular mechanisms that lead to its progression, with the hope of providing future direction in the management of DN. To improve the approaches to diabetic management, the suggested resolutions in the literature are also discussed in this review. This review will provide an in-depth understanding of the causative mechanisms of DN, apart from the insights to improve the quality and strategic approaches to DN management.