The origin of the cannula for ventriculostomy in pediatric hydrocephalus

Medical and surgical texts from the 16th to the 18th centuries document the origin of the cannula for ventriculostomy in pediatric hydrocephalus. Fabrizio d'Acquapendente was the first physician to report external ventriculostomy through the insertion of a silver cannula with a stopper. More than 100 years later, extended use of the trocar by urologists allowed Claude-Nicolas Le Cat to perform an external ventriculostomy with a trocar and a bung.     

Overdrainage in the treatment of hydrocephalus]

In infants or children, hydrocephalus is usually the consequence of an obstacle in the cerebro-spinal fluid (CSF) pathways and is most frequently treated by the insertion of a ventriculo-peritoneal shunt (rarely ventriculo-atrial). The CSF flow through such a shunt is equal to the ratio of the difference (DP) between the CSF input and output pressures over the valve resistance. When the child is in the upright position, a DP increase occurs due to the height of the hydrostatic column between the inlet and the shunt outlet. Thus if the shunt drains correctly in the prone position, it overdrains in the upright position. As the CSF flow through the shunt in standing patients is higher than the CSF secretion, the excess fluid will be taken out of the ventricles, resulting in pericerebral collections, slit ventricles or post-shunt craniostenoses. Many different techniques have been proposed to reduce overdrainage. The Orbis-Sigma shunt was designed in the "Service des Enfants-Malades" precisely for this purpose. In the upright position this shunt becomes a flow regulator and thus reduces overdrainage. Its use has decreased by 2-fold the number of mechanical complications related to overdrainage.     

儿童结核性脑膜炎脑积水Ommaya囊内注药外引流治疗的体会

目的 探讨Ommaya储液囊治疗儿童结核性脑膜炎脑积水的疗效.方法 结核性脑膜炎伴脑积水患儿12例,男9 例,女3例,体重6～38 kg,年龄4个月至12岁.Ⅱ级6例,Ⅲ级4例,Ⅵ级2例.12例均采用储液囊植入,囊内穿刺引流、注药方法治疗.结果 术前脑脊液白细胞数、蛋白含量分别是:(228±139)×106/L、(2.18±1.26) g/L;储液囊内给药2周后白细胞数(21±18)×106/L、蛋白含量(0.69±0.34) g/L.植入12个储液囊,最终取出储液囊8个,长期留置4个,4例再次行V-P分流术.结论 Ommaya储液囊具有操作方便,可随时反复抽取脑脊液检查,避免腰穿;留置时间长,不易感染;经囊内给药起效快等优点.此方法可能更适用于轻中度脑积水且预计短期内脑积水可缓解的患儿.部分患儿可避免长期分流管的植入.     

Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus

This study was designed to evaluate the indications for ventriculoperitoneal shunting in cases of children with tubercular meningitis, presenting with hydrocephalus. Thirty seven children (less than 18 years of age) of tubercular meningitis with hydrocephalus (TBMH) who underwent ventriculoperitoneal shunting over a three year period (1999 to 2001) were included in the study. Sixteen (43%) children were Palur stage II, 15 (40%) stage III, and 6 (16%) stage IV. Fifteen (40%) children had received antitubercular therapy for less than 4 months and 17 (46%) received therapy for more than 4 months prior to presentation. Five (14%) children had not previously received antitubercular therapy. Shunt related complications occurred in 11 (30%) children and 3 children had undergone revision of the shunt multiple times. Good outcome was seen in 16 (43%) children. Thirteen (35%) had moderate disability and 6 (16%) had severe disability at 3 months of follow up. 62% (n =10) children in grade II had a good outcome compared to 40% (n = 6) in grade III. All six children in grade IV had a poor outcome. 2 children, both having multiple infarcts, died and the remaining 4 were left with severe disability. We recommend shunt placement in all children of grade II and III TBMH as this policy has yielded the best results. For grade IV children external ventricular drainage, followed by shunting if improvement occurs remains the most cost-effective procedure.     

The treatment of pediatric migraine

The management of pediatric migraine requires a balance of biobehavioral measures coupled with agents for acute treatment and, if needed, daily preventive medicines. A recent American Academy of Neurology practice parameter has critically reviewed the limited data regarding the efficacy and safety of medicines for the acute and preventive therapy of pediatric migraine. The first step is to establish the headache frequency and degree to which the migraines impact upon lifestyle and performance. The next step is to institute nonpharmacologic measures such as regulation of sleep (improved sleep hygiene), moderation of caffeine, regular exercise, and identification of provocative influences (eg, stress, foods, social pressures). A wide variety of therapeutic options exist for patients whose migraine headaches occur with sufficient frequency and severity to produce functional impairment. The most rigorously studied agents for the acute treatment of migraine are ibuprofen, acetaminophen, and sumatriptan nasal spray, all of which have shown safety and efficacy in controlled trials. Daily preventive drug therapies are warranted in about 20% to 30% of young migraine sufferers. The particular drug selected for the individual patient requires an appreciation of comorbidities such as affective or anxiety disorders, co-existent medical conditions such as asthma or diabetes, and acceptability of potential toxicities such as weight gain, sedation, or tremor.     

Conservative treatment of non-resorptive hydrocephalus in premature infants

Following perinatal asphyxia and intracranial hemorrhage frequently progressive ventricular dilatation develops in preterm infants. Most common is communicating hydrocephalus due to obliterative arachnoiditis. Ventricular dilatation is reported to affect normal brain development and early therapy is recommended. Cerebrospinal fluid shunting is still accompanied by multiple complications, esp. in preterm infants with a birth-weight below 1,500 g. Seven preterm infants, born between the 27th and 34th gestational week with a birthweight of 910-1,940 g were medically treated for their progressive communicating hydrocephalus. The therapy consisted of intermittant lumbar punctures, medication of acetazolamide and furosemide as well as electrolyte and base replacement. Therapy was started at the 14th-31st postnatal day and lasted from 46 to 149 days. In all children the ventricular dilatation diminished. A steady state of cerebrospinal fluid production and absorption was regained in four children. Due to reoccurrence of ventricular dilatation shunting was performed in three others at the age of more than 3 months and with a weight of 3,620-5,170 g. Thus, medical therapy of hydrocephalus provides time for development of preterm infants, delay of shunting procedures and normalisation of cerebrospinal fluid dynamics.