Extracorporeal ventriculoatrial shunt with the use of one-way ball valve

We developed a simple system of an "extracorporeal" ventriculoatrial (VA) shunt using a one-way ball valve (Acty valve II, Kaneka Medix) to release the patient from postoperative constraint during the ventricular drainage. The system is constructed in such a way that the ventricular drainage tube is connected to the central venous catheter via a one-way valve. The CSF is regulated by using the valve and is diverted into the systemic circulation as in the conventional ventriculoatrial shunt. After 2 or 3 weeks of CSF diversion through the extracorporeal VA shunt, a ventriculoperitoneal shunt is placed if hydrocephalus is apparent by temporary occlusion of the system. We applied this system to 4 patients with hydrocephalus, and we found it useful and free from adverse effects. The patient was freed from physical constraint involved in conventional ventricular drainage and an effective program of early rehabilitation was able to be started.     

Postoperative hydrocephalus in cranial base surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.     

Postoperative Hydrocephalus in Cranial Base Surgery

The incidence of postoperative hydrocephalus and factors relating to it were analyzed in 257 patients undergoing cranial base surgery for tumor resection. A total of 21 (8%) patients developed postoperative hydrocephalus, and all required shunting, Forty-two (17%) patients developed cerebrospinal fluid (CSF) leak that required placement of external drainage systems (ventriculostomy or lumbar drain, or both); 10 (23%) of these 42 patients eventually needed shunt placement to stop the leak because of hydrocephalus. Prior craniotomy, prior radiation therapy, and postoperative CSF infection were also associated with an increased risk of developing hydrocephalus (48% versus 6%, 19% versus 8%, and 14% versus 7%, respectively). Prior radiation and postoperative CSF infection increased the risk of CSF leak in patients with hydrocephalus (30% versus 18% and 30% versus 9%, respectively). CSF leak and hydrocephalus commonly occurred in patients who underwent resection of a glomus tumor. In conclusion, 8% of patients who underwent cranial base surgery for tumors developed de novo hydrocephalus; half of them also had CSF leak in addition to hydrocephalus; and all required shunt placement for CSF diversion.     

Factors causing acute shunt infection. Computer analysis of 1174 operations

A series of 1174 operations performed on 802 hydrocephalic children was analyzed in an effort to find the factors causing acute postoperative infection. Culture of the cerebrospinal fluid (CSF) samples during the operation was positive in 33 cases. These cases were excluded from the series. Ninety infections were observed in the remaining 1141 operations, an overall rate of 7.9%. Most of these infections were meningitis (56 cases). Staphylococcus epidermidis was the bacterium most frequent identified (44%). Statistically significant relationships were found between shunt infection and the following factors: 1) age: infection was 2.6 times as frequent before 6 months than after 1 year of age (p = 0.03); 2) poor condition of the skin; 3) presence of intercurrent seats of infection at the time of surgery; 4) type of operation: the rate of infection was 8.4% in primary shunt insertions, 5% in shunt revisions, and 17.5% in reinsertions following shunt removal for infection (p = 0.0001); 5) end of the shunt requiring revision: an infection rate of 7.7% followed revision of the ventricular catheter alone, and 2.6% followed revision of the other end alone (p = 0.012); and 6) postoperative wound dehiscence or scalp necrosis. The surgical team involved was poorly correlated with the rate of infection (p = 0.12). No statistically significant relationships have been found between infection and 1) etiology of hydrocephalus: 2) sex; 3) recent neurosurgical operation before the shunt procedure; 4) preoperative presence of an external drainage tube or CSF fistula; 5) lumbar or ventricular taps, or ventriculography; 6) number of previous operations performed on the shunt; 7) time (month and year) of operation; or 8) sugar level and cell count in the CSF.     

Comparison of clinical outcomes of intraventricular hematoma between neuroendoscopic removal and extraventricular drainage

The efficacy of treatment for intraventricular hematoma by neuroendoscopic surgery and extraventricular drainage was compared in 10 patients with intraventricular hematoma and hydrocephalus who underwent neuroendoscopic surgery (endoscopic group), and eight patients with intraventricular hematoma and hydrocephalus treated with extraventricular drainage (EVD group). The outcomes in each group were assessed retrospectively using the Graeb scores on the pre- and postoperative computed tomography (CT), duration of extraventricular drainage, requirement for a shunt operation, and modified Rankin scale score at 12 months. The Graeb scores on the preoperative CT were not significantly different between the two groups, but the duration of catheter placement was significantly shorter (69.3%) in the endoscopic group (2.7 days) than in the EVD group (8.8 days). None of the patients in either group required a shunt procedure for communicating hydrocephalus 12 months after surgery. Neuroendoscopic removal is a safe and effective procedure for intraventricular hematoma. Advantages include rapid removal of hematoma in the ventricular systems and reliable improvement of non-communicating hydrocephalus in the acute phase. The procedure resulted in faster removal of the catheter in the postoperative period and earlier patient ambulation.     

Transfrontal pituitary surgery: Clinical results,intraoperative management,and postoperative monitoring

Summary Sixty-nine cases of pituitary tumours with suprasellar extensions are reviewed. Twenty cases were recurrent. All were removed via a frontal craniotomy and surgery was performed under moderate hypothermia in all except seven cases. In 59 cases, lumbar cerebrospinal fluid (CSF) drainage was performed in order to improve operating conditions. Amongst 42 primary cases, 29 (69%) were uncomplicated, 5 (12%) developed severe transient complications and one (2.4%) had a persistent deficit postoperatively; there were no deaths. Amongst 17 recurrent cases, 6 (35%) were uncomplicated; there were five deaths (29%) in the immediate postoperative period and one patient had a persistent deficit (6%).Acute hypertension and/or bradycardia were seen in 32 cases (54%) at the time of lumbar CSF drainage. These included all those who subsequently died and 10 of the 12 cases who developed severe complications. In 7 cases where ventricular CSF drainage was performed intraoperatively, one showed acute hypertension accompanying brain retraction but there were no postoperative complications. Two of these cases were recurrent.Postoperative intracranial pressure, measured epidurally, varied widely in both complicated and uncomplicated cases and was frequently low (less than 10–15 mm Hg) in the presence of severe complications.It is concluded that lumbar CSF drainage should not be performed in the presence of a suprasellar extension and that postoperative monitoring of the epidural pressure is of little value in these cases for the early detection of postoperative complications pertaining to the operative field.     

Treatment of hydrocephalus in adults by placement of an open ventricular shunt.

OBJECT: Ventricular shunt placement is the neurosurgical procedure most frequently associated with complications. Over the years, it has been a growing concern that the performance of most shunting devices does not conform to physiological parameters. An open ventriculoperitoneal (VP) bypass with a peritoneal catheter for which the cross-sectional internal diameter was 0.51 mm as a distinctive element for flow resistance was evaluated for use in the treatment of adult patients with hydrocephalus. METHODS: During a 2-year period, open shunts were surgically implanted in 54 adults with hydrocephalus; conventional shunts were implanted in 80 matched controls. Periodic evaluations were performed using neuroimaging studies and measures of clinical status. All patients were followed from 12 to 36 months. 18.5 +/- 4 months for patients with the open shunt and 19.1 +/- 8.1 months for controls (mean +/- standard deviation). The device continued to function in 50 patients with the open shunt (93%) and in 49 controls (61%: p < 0.001). The Evans index in patients with the open shunt was 0.33 +/- 0.09 throughout the follow up. No cases of infection, overdrainage, or slit ventricles were observed: the index in controls was 0.28 +/- 0.08; 60% of them developed slit ventricles. During the follow-up period occlusion occurred in four patients with the open shunt (7%) and in 31 controls (39%: p < 0.001). CONCLUSIONS: The daily cerebrospinal fluid (CSF) drainage through the open VP shunt is close to 500 ml of uninterrupted flow propelled by the hydrokinetic force generated by the combination of ventricular pressure and siphoning effect. It complies with hydrokinetic parameters imposed by a bypass connection between the ventricular and peritoneal cavities as well as with the physiological archetype of continuous flow and drainage according to CSF production. The open shunt is simple, inexpensive, and an effective treatment for hydrocephalus in adults.     

Shunt surgery for hydrocephalus in tuberculous meningitis: a long-term follow-up study

Hydrocephalus is a common complication of tuberculous meningitis. Case studies of 114 patients with tuberculous meningitis and hydrocephalus, who underwent shunt surgery between July, 1975, and June, 1986, were reviewed to evaluate the long-term outcome and to outline a management protocol for these patients based on the results. Seven factors were studied in each case: 1) age at admission; 2) grade on admission (I to IV, classified by the authors; Grade I being the best and Grade IV being the worst); 3) duration of alteration of sensorium; 4) cerebrospinal fluid (CSF) cell content at initial examination; 5) CSF protein levels at initial examination; 6) number of shunt revisions required; and 7) the necessity for bilateral shunts. During a long-term follow-up period ranging from 6 months to 13 years (mean 45.6 months), the mortality rate was 20% for patients in Grade I; 34.7% for patients in Grade II; 51.9% for patients in Grade III; and 100% for patients in Grade IV. Only the grade at the time of admission was found to be statistically significant in determining final outcome (p less than 0.001). Based on these results, the authors advocate early shunt surgery for Grade I and II patients. For patients in Grade III, surgery may be performed either if external ventricular drainage causes an improvement in sensorium or without selection. All patients in Grade IV should undergo external ventricular drainage and only those who show a significant change in their neurological status within 24 to 48 hours of drainage, should have shunt surgery.     

Low pressure hydrocephalus: issues of diagnosis and treatment in five cases

Five patients with hydrocephalus who failed to respond to apparently adequate CSF drainage via a functioning shunt (four cases) or external ventricular drain (one case) are described. In three of the four shunted cases, the shunt was ventriculoperitoneal with a medium pressure valve, and in one a combination of peritoneal and atrial shunts both with low pressure valves. All five patients were tested for possible low pressure hydrocephalus by a period of external ventricular drainage at heights of 0 to -5 cm H2O below the reference point (external auditory meatus--EAM). Four of the five patients showed rapid and significant clinical improvement and went on to shunt revision (three) or insertion (one). The shunts were then all peritoneal, of which three were valveless, whilst one had a Sophy programmable valve at the lowest setting. In all four patients the improvement was sustained and was associated with a radiological (CT or MRI) improvement which varied from marked to slight. In the fifth patient there was no improvement with low pressure external drainage and no shunt revision was undertaken. On the basis of these cases the possible entity of low pressure hydrocephalus is discussed with particular reference to mechanism, recognition and management.     

A long-term ventricular drainage for patients with germ cell tumors or medulloblastoma

BACKGROUND: Hydrocephalus associated with intracranial germ cell tumors or disseminated medulloblastoma has been treated with ventriculoperitoneal shunt. However, this procedure has a potential risk of intraperitoneal metastasis of these brain tumors. To prevent this potential risk and to minimize the risk of infection, we developed a percutaneous long-tunneled ventricular drainage (PLTVD). To confirm the effectiveness, we retrospectively analyzed the results of this procedure. METHODS: From 1979 to 2003, we have treated 96 patients with germ cell tumors and medulloblastoma in our hospital. Of 96 patients, 59 (germ cell tumor, 31; medulloblastoma, 28) had hydrocephalus and 13 needed long-term cerebrospinal fluid drainage to manage the obstructive hydrocephalus due to persistent tumor or communicating hydrocephalus due to dissemination. We performed PLTVD for these cases using a flow-controlled shunt device and percutaneous long-tunneled shunt tube (peritoneal catheter) exiting at the upper abdomen and connecting to a closed drainage system. The occurrence of extraneural metastasis and the incidence of infection were evaluated. RESULTS: The average duration of drainage was 74 days (range, 34-115 days). All 13 cases received full-dose chemotherapy and radiotherapy without infectious complications or extraneural metastasis. CONCLUSIONS: Percutaneous long-tunneled ventricular drainage was an effective method to manage long-lasting obstructive or communicating hydrocephalus with germ cell tumors and medulloblastoma.     

Volumetric measurements in the detection of reduced ventricular volume in patients with normal-pressure hydrocephalus whose clinical condition improved after ventriculoperitoneal shunt placement

OBJECT: The syndrome of normal-pressure hydrocephalus (NPH) refers to the clinical triad of gait disturbance, dementia, and urinary incontinence in association with idiopathic ventriculomegaly and normal intracranial pressure. Ventriculoperitoneal (VP) shunt placement often yields significant clinical improvements, sometimes without apparent reduction of ventricular size. The authors hypothesized that careful volumetric measurements would show a decrease in ventricular volume in these patients. METHODS: Twenty consecutive patients with NPH underwent placement of VP shunts equipped with programmable valves. In 11 patients pre- and postoperative neuroimaging was performed, which allowed volumetric analysis. Volumetric measurements of the lateral ventricles were calculated in triplicate by National Institutes of Health image-processing software to assess standard computerized tomography (CT) scans (eight patients) or magnetic resonance (MR) images (three patients) obtained before and after shunt placement. Ventricular volumes were also assessed by an independent neuroradiologist. Postoperative studies were performed at a time of clinical improvement, between 1 and 9 months postsurgery (mean 5 months). Preoperative and postoperative Unified Parkinson's Disease Rating Scale evaluations were performed in four patients. Significant clinical improvement occurred in all patients after shunt placement (mean follow-up period 17.5 months). Although 10 (91%) of 11 patients demonstrated a calculable decrease in volume in the lateral ventricles (mean decrease 39%), formal interpretation of neuroimages indicated a definite decrease in lateral ventricular volume in only three (27%) of 11 patients. CONCLUSIONS: Volumetric measurements obtained to compare preoperative and postoperative CT or MR studies obtained in patients with NPH in whom clinical improvement was seen after shunt placement surgery show a demonstrable decrease in ventricular size. Volumetric measurements may be helpful in clinical assessment postoperatively and in guiding programmable valve pressure settings.     

Multiloculated hydrocephalus related to cerebrospinal fluid shunt infection

Summary This study is an attempt to establish that CSF shunt infection has a role in the aetiology of multiloculated hydrocephalus. The authors carried out a review of 12 cases of multiloculated hydrocephalus who were treated at King Khalid University Hospital between 1988–1994. The multiloculation appears to have developed following the shunt infection in all cases. The hydrocephalus was related to an intraventricular haemorrhage (IVH) in 9 patients and was congenital in 2 patients and post-meningitic in 1 patient. The shunt infection was caused by a gram-negative organism in 8 patients and duration of external ventricular drainage ranged from 9–24 (median 13) days. The diagnosis of multiloculated hydrocephalus was made on average 2 months after the shunt infection. In three patients endoscopic fenestration of intraventricular septations was attempted but was effective in only one case. The other patients were managed by two shunts (9 patients) and three shunts (2 patients). At a mean follow-up of 15 months, the shunt revision rate of the patients was 0.4/year. One patient died of multiple brain abscesses and 6 patients remain severely disabled. The poor outcome may also be related to the original IVH as well as the multiloculated hydrocephalus.The study also shows that patients with post-haemorrhagic hydrocephalus, who develop a shunt infection due to gram-negative organisms and in whom the CSF fails to be cleared of the infection following 12 days of external drainage appear to be at risk of developing multiloculated hydrocephalus.     

The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis of 108 patients

The effects of continuous drainage of cerebrospinal fluid (CSF) on vasospasm and hydrocephalus were analyzed retrospectively in 108 patients with subarachnoid hemorrhage (SAH) who were operated on for ruptured aneurysms within 48 hours of their onset. Ninety-two of these patients underwent a procedure for CSF drainage (cisternal drainage, ventricular drainage, lumbar drainage, or a combination of these). The duration, the total volume, and the average daily volume of CSF drainage were 10.4 +/- 7.0 days (mean +/- SD). 2034 +/- 1566 ml, and 190 +/- 65.3 ml, respectively. Patients with a greater drainage volume at a lower height of drainage in the early period after SAH developed more cerebral infarctions later (P less than 0.025). The relationship between the total volume of CSF removed and shunt-dependent hydrocephalus was determined to be statistically significant (P less than 0.005). Cerebral infarction and hydrocephalus after SAH were also found to be statistically associated (P less than 0.001). Thus, continuous cerebrospinal fluid drainage should not be performed too readily in patients with SAH, because the removal of a large amount of CSF can induce cerebral vasospasm as well as hydrocephalus.     

Neuroendoscopic approach to complex hydrocephalus. Personal experience and preliminary report

BACKGROUND: Neuroendoscopic premammilary third-ventriculocisternostomy in non-communicating hydrocephalus represents, to date, the less invasive and effective procedure, whereas the neuroendoscopic approach to complex-hydrocephalus is limited to several small anecdotal series. METHODS: Among 57 pediatric patients affected by obstructive hydrocephalus, ranging in age from prenatal diagnosis to 3 years (mean 1.2 year+/-11 months) and recruited over a 2-year period, we identified 11 cases with presurgical neuroradiological complex-hydrocephalus, at admission to our Department. In two cases Magnetic Resonance imaging showed bilateral atresic foramen of Monro and corpus callosum agenesya. In these cases an extracranial cerebrospinal fluid shunt device was implanted. The authors report retrospectively, the personal experience on a series of 9 pediatric patients with complex-hydrocephalus, such as multishunted (4 cases), multiloculated hydrocephalus (3 cases), and multiple ventricular cysts plus hydrocephalus (2 cases), in which a neuroendoscopic approach was performed. At admission, symptoms and signs of an increased intracranial pressure were presents in all cases. Follow-up ranged from 3 months to 2 years. In 8 cases third ventriculostomy was successfully performed whereas, in one case, the endoscopic procedure, in a patient younger than 1 month, was aborted and an extracranial cerebrospinal fluid device was implanted. RESULTS: In the postoperative period and during follow-up, a symptomatic relief and clinical improvement of preoperative signs and symptoms of increased intracranial pressure was seen in all cases. Nevertheless, in two patients psychomotor retardation worsened, respectively 6 and 7 months after the endoscopic procedure and then, an additional extracranial cerebrospinal fluid shunt device was implanted. CONCLUSIONS: In our selected cases of complex-hydrocephalus, the neuroendoscopic approach did not fail to determine clinical improvement after the first procedure, in spite of increased technical difficulties and minimum decreases of ventricular volume in postoperative images.     

CSF drainage in patients with posterior fossa tumours

Summary The management of hydrocephalus secondary to a posterior fossa tumour is controversial. We audited recent practice with a retrospective analysis of 287 consecutive patients undergoing posterior fossa exploration for tumour. 85 shunts and 112 external ventricular drains (EVD) were placed. The overall CNS infection rate in the series was 6%. There was a significantly higher (p < 0.01) infection rate in patients who had a drainage procedure, and a trend towards higher infection rates in patients with two drainage procedures. Early infection rates with EVDs and shunts were the same (7%). One third of patients with hydrocephalus had pre-operative drainage, a third had per-operative drainage but only a quarter required a permanent shunt.The majority of patients will not require a permanent shunt and where temporary CSF diversion is required EVD is reasonable.     

Post-traumatic hydrocephalus.

BACKGROUND: Surgical treatment of ventricular dilatation following severe head trauma (GCS <8) remains controversial due to the difficulty to distinguish brain atrophy-related ventriculomegaly from active, symptomatic ventricular dilatation. Consequently, the reported incidence of post-traumatic hydrocephalus in literature varies greatly from 0.7-29%. The presence of ventricular dilatation following severe head trauma should be considered and demands investigation, based also on satisfactory results obtained with cerebrospinal fluid (CSP) shunting, METHODS: Ninety-eight patients with post-traumatic hydrocephalus undergoing CSF shunting were selected for this study among 4,044 patients with severe head trauma treated from 1972 to 1999 at the Department of Neurosurgery at the City Hospital of Verona. Patients included 82 (84%) males and 16 (16%) women, ranging from one month to 83 years (mean age; 39 years). In 24 (24%) cases, the brain trauma lesion was single, while in 74 (76%) cases the patient suffered multiple cranio-cerebral lesions. The total number of lesions was 230 including 214 (93%) supratentorial and 16 (7%) posterior cranial fossa (PCF) lesions. Seventy-nine operations were performed on 59 (60%) patients. The onset of hydrocephalus was immediate after trauma in 14 (14%) cases, whereas a delayed onset was observed within 30 days in 44 (45%) cases, between one-four months in 30 (31%) cases and between four-six months in 10 (10%) cases. Of the 98 patients in this study, 15 were treated with an external CSF shunt and 83 underwent internal CSF shunting. RESULTS: Long-term results of the 15 patients with external shunts demonstrated good recovery in 13% while 87% of cases resulted in death. In the 83 cases of internal shunts, despite severe preoperative conditions (75% in coma or persistent coma), the results were as follows: good recovery in 37 (45%) patients, partial disability in nine (11%), persistent coma in 29 (35%) and death in seven (8%) cases. CONCLUSIONS: Post-traumatic hydrocephalus is a complication that must always be considered in cases of severe head trauma (GCS <8) in young patients presenting added neurological deficits, ceased clinical improvement (ceased improvement after initial improvement), increased hypertonia, surgical flap tension or CSF accumulation. The results of this study suggest the necessity to treat post-traumatic ventricular dilatation with aggressive surgery and CSF shunting, based on favorable outcome seen even in coma and persistent coma patients.     

Liver abscess secondary to ventriculoperitoneal shunt

Liver abscess is a rare complication following the ventriculoperitoneal (V-P) shunt operation. There has been only one case reported in the literature. We present a case of liver abscess developed about 3 months after V-P shunt operation. A 31-year-old female was admitted to our hospital in comatose condition due to second bleeding from an aneurysm of the right internal carotid artery on January 1, 1984. Obliteration of the aneurysm was performed on the following day. She received V-P shunt operation for the marked hydrocephalus on February 4, but she developed low spinal fluid pressure syndrome. She was able to walk by herself after the replacement of shunt valve on March 4. In the middle of April, she suffered from abdominal pain with a pyrexia for about 5 days. On May 13, a new peritoneal tube was placed in another part of the peritoneal cavity because of the recurrence of hydrocephalus. On the following day, she developed severe abdominal and back pains with a high fever. Abdominal CT scans and ultrasonogram were performed on May 22, showing a well-defined, cystic mass lesion in the liver and the peritoneal tube lying just beneath the mass lesion. Approximately 100 ml of white creamy pus was aspirated from the cystic mass by ultrasound-guided percutaneous puncture, and a 8.3 French pigtail nephrostomy catheter was left in place for 9 days until purulent drainage stopped. Microbiologic examination demonstrated staphylococcus epidermidis in the cerebrospinal fluid (CSF) from the shunt tube but was negative in the abscess fluid. The ventricular fluid was drained externally with the V-P shunt tube for a while, but the new ventricular drainage was instituted because of continuous positive cultures in the CSF from the shunt tube. Thereafter, the cultures of the CSF became negative and ventriculoatrial (V-A) shunt operation was performed on July 2. Postoperative course was uneventful. It is considered that the formation of the liver abscess seems to be caused by the focal injury to the liver surface by the insidiously infected peritoneal tube with St. epidermidis, and by the decrease in systemic resistance to infection. Percutaneous aspiration and drainage under the guidance of abdominal computed tomography or ultrasonography are very useful and efficient for the diagnosis and the treatment of liver abscess. When patients show signs of infection to the V-P shunt, we should remove the shunting system and place a new external ventricular drainage, and institute a V-A shunt after confirming negative cultures of the CSF.     

Results of surgical treatment of neurocysticercosis in 69 cases

The clinical course of 69 patients with neurocysticercosis who underwent surgery to control increased intracranial pressure (ICP) or cyst removal is analyzed. Increased ICP was caused by hydrocephalus in 63 patients, by cerebral edema in four, and by giant cysts in two. Skull x-ray films showed calcifications in 14% and signs of elevated ICP in 46%. Examination of cerebrospinal fluid (CSF) revealed pleocytosis with eosinophils in 52% of cases and a positive complement fixation test for cysticercosis in 66%. Ventriculography allowed localization of the CSF obstruction and ventricular cysts, and generally differentiated between an obstruction due to cysts and an inflammatory process. Computerized tomography showed cysts in the cerebral parenchyma and ventricular dilatation. Ventricular cysts were best seen when intraventricular metrizamide was used. Intracranial shunting and posterior fossa exploration were less effective in the treatment of hydrocephalus than was ventriculoatrial (VA) or ventriculoperitoneal (VP) shunting, although VA or VP shunting was associated with a high percentage of complications. Quality of survival was good in 87% of the cases in the first 3 postoperative months and in 93% of patients who survived 2 years after surgery. Forty-seven patients (68%) were readmitted one or more times for CSF shunt revision; 14 of them for shunt infection (meningitis). The early operative mortality rate was 1.8% for patients with VA or VP shunt placement and 5.3% for those with posterior fossa exploration. The authors conclude that placement of CSF shunts is indicated in the treatment of hydrocephalus, and cyst removal is indicated only when the cyst exhibits tumor-like behavior. Surgical exploration is also indicated when the diagnosis is uncertain.     

Cerebral blood oxygenation after cerebrospinal fluid removal in hydrocephalus measured by near infrared spectroscopy

BACKGROUND: The cerebrospinal fluid (CSF) tap test has been used for the diagnosis of chronic hydrocephalus to identify the candidates for surgical CSF shunting. However, a high rate of false negative results limits it utility. The purpose of this study is to investigate whether the concomitant monitoring of cerebral hemodynamics by near infrared spectroscopy (NIRS) can improve the diagnostic accuracy of the tap test. METHODS: Thirteen patients with dilated ventricular system were candidates for this study. We assessed for the patterns of cerebral blood oxygenation (CBO) change in hydrocephalus to determine whether CBO change after CSF removal is useful for selecting shunt candidates. RESULTS: Patients who showed clinical improvement following CSF shunting had a characteristic CBO change with increases in the concentration of oxyhemoglobin (Oxy-Hb), and patients without improvement during continuous CSF drainage test showed no increase in Oxy-Hb. CONCLUSION: The current data suggests that CBF increases after CSF removal in hydrocephalus. Although the patients utilized in the present study had secondary chronic hydrocephalus, we speculate that these data could be applied to patients with idiopathic chronic hydrocephalus. Further investigation would be of benefit.     

Neuroendoscopic stent procedure in obstructive hydrocephalus due to both foramina of monro occluding craniopharyngioma: technical note

BACKGROUND: The development of various neuroendoscopic surgical instruments has offered more options for endoscopic procedures in the treatment of intraventricular tumors. Not only tumor biopsy or tumor resection but also restoration of an obstructed cerebral spinal fluid (CSF) pathway can be performed using the same approach. METHOD: A 76-year-old woman with a cardiac pacemaker for an underlying heart disease was diagnosed with obstructive hydrocephalus because of a third ventricular tumor 8 years ago. The patient had been treated with ventriculo-peritoneal shunt placement. At admission she presented with a subcutaneous infection of the shunt catheter and an abdominal mass of unknown etiology. Neuroendoscopic stenting between lateral and third ventricle was performed to restore the obstructed CSF pathway, and the infected shunt system was removed in the same setting. RESULT: The postoperative course was uneventful. Contrast ventriculography demonstrated a restored CSF pathway between the lateral and third ventricle. Histologic examination of the intraventricular tumor revealed a craniopharyngioma, and the abdominal mass was diagnosed as a gastrointestinal adenocarcinoma. CONCLUSION: The neuroendoscopic foraminoplasty technique should be considered as an alternative treatment for patients who present with an obstructive hydrocephalus caused by a tumor that occludes both foramina of Monro when shunt placement or endoscopic third ventriculostomy is not feasible.