Hyponatraemia caused by repeated cerebrospinal fluid drainage in post haemorrhagic hydrocephalus.

Three hyponatraemic infants had post-haemorrhagic hydrocephalus which was treated by repeated drainage of cerebrospinal fluid. Each required oral sodium supplements. The concentration of sodium in the cerebrospinal fluid was such that as much as 3 mmol of sodium could have been removed with each ventricular tap. Serum sodium concentrations should be monitored closely in any infant requiring regular drainage of cerebrospinal fluid.     

Pump-regulated cerebrospinal fluid drainage

The drainage of cerebrospinal fluid (CSF) from the lumbar subarachnoid space is an effective technique for the treatment of CSF fistula and control of intracranial pressure in children and adults. The use of the lumbar drain poses unique challenges, however, in the pediatric population. We present a safe and effective method of pump-controlled lumbar subarachnoid drainage. This technique allows accurate titration of CSF removal while providing a closed system which is not sensitive to position changes or patient activity. Four case histories are reviewed.     

Lactic dehydrogenase isoenzymes in cerebrospinal fluid associated with hydrocephalus

Various neurological disorders are associated with specific changes in the level of total lactic dehydrogenase and concentrations of its isoenzymes in the cerebrospinal fluid. We describe the lactic dehydrogenase isoenzyme values in children with hydrocephalus. Cerebrospinal fluid samples collected from 10 patients (2 to 16 mo) with hydrocephalus were analysed for total lactic dehydrogenase activity and lactic dehydrogenase isoenzymes. Findings were compared with those in samples from 15 paediatric patients, with normal results. Mean total lactic dehydrogenase activity in the cerebrospinal fluid was significantly higher in the patients with hydrocephalus (101 +/- 23.11 U/L) than in the controls (33.53 +/- 5.75 U/L) (p <0.001). In the control samples, lactic dehydrogenase-1 was the main fraction, followed by lactic dehydrogenase-2 and 3; only small concentrations of lactic dehydrogenase-4 and lactic dehydrogenase-5 were detected. By contrast, patients with hydrocephalus had lower concentrations of the lactic dehydrogenase-1 fraction and higher lactic dehydrogenase-2 and lactic dehydrogenase-3 concentrations, the differences between these results and those in the control group being statistically significant (p < 0.001). The values for lactic dehydrogenase-4 and lactic dehydrogenase-5 were similar in both groups. Conclusion: Findings should be considered together with computed tomography/magnetic resonance imaging and ultrasound scans. The cerebrospinal fluid lactic dehydrogenase profile may prove to be an important predictor of cerebral injury, obstructive hydrocephalus and long-term neurodevelopmental problems.     

Posthemorrhagic unilateral hydrocephalus: fenestration of septum pellucidum as an alternative to shunt implantation

Unilateral hydrocephalus caused by occlusion of the foramen of Monro is rare. We report two cases in neonates caused by prenatal hemorrhage, their radiographic findings, and surgical treatment. With posthemorrhagic progressive unilateral hydrocephalus, early intervention with fenestration of septum pellucidum should be considered.     

Increased hypoxanthine concentrations in cerebrospinal fluid of infants with hydrocephalus

Hypoxanthine, the end product of purine metabolism, is usually very elevated in body fluids during severe hypoxia. We measured hypoxanthine in the cerebrospinal fluid of hydrocephalic preterm infants (12 with posthemorrhagic, one with congenital hydrocephalus) to determine whether hydrocephalus is associated with anaerobic metabolism of brain tissue. Cerebrospinal fluid hypoxanthine was undetectable in normal infants. In hydrocephalic infants, the concentration of hypoxanthine ranged from 7.5 mumol/L to 28 mumol (means = 14.3 mumol/L). The hypoxanthine concentrations fell from a mean of 12.8 mumol/L to a mean of 2.0 mumol/L (P less than 0.05) with successful treatment of the ventriculomegaly by lumbar puncture or by ventriculoperitoneal shunt. Patients with acute posthemorrhagic hydrocephalus had similar concentrations of hypoxanthine (means = 14.5 mumol/L) as patients with late or with congenital hydrocephalus (means = 13.8 mumol/L), indicating that brain hypoxia is probably a consequence of the ventriculomegaly and not of the hemorrhagic insult.     

Alterations in spinal fluid drainage in infants with hydrocephalus

We describe two cases of hydrocephalus in which spinal sonography revealed underlying causes responsible for the failure of therapeutic lumbar punctures.     

Serum C-reactive protein test in diagnosis of septic complications of cerebrospinal fluid shunts for hydrocephalus.

Serial tests for serum C-reactive protein (CRP) were carried out on 40 children undergoing cerebrospinal fluid shunt surgery, to determine the pattern of appearance and disappearance of CRP in relation to this type of operation, in the absence of postoperative complications. Samples of sera from a further 268 children, 79 of whom presented after shunt surgery with symptoms suggesting infective complications related to the shunt, were examined for CRP. The results showed that, while the test in negative in uncomplicated colonisation of ventriculo-atrial shunts, it is reliably positive in patients with colonised ventriculo-peritoneal shunts, ventriculitis, or shunt nephritis.     

Procollagen I C-propeptide in the cerebrospinal fluid of neonates with posthaemorrhagic hydrocephalus

BACKGROUND: The pathogenesis of posthaemorrhagic hydrocephalus (PHHC) following intraventricular haemorrhage (IVH) in premature infants includes a fibroproliferative reaction leading to arachnoidal fibrosis, ultimately causing malresorption of cerebrospinal fluid (CSF) at the arachnoid villi. AIMS: To determine whether an increased concentration of the carboxyterminal propeptide of type I procollagen (PICP) in the CSF of neonates after IVH reflects the activation of collagen synthesis preceding the manifestation of PHHC. METHODS: From 20 neonates with PHHC (median birth weight 740 g, median gestational age 25+1 weeks), 52 CSF samples were collected. CSF samples of four neonates (median birth weight 2170 g, median gestational age 32+4 weeks) with congenital non-haemorrhagic hydrocephalus served as controls. PICP was measured by radioimmunoassay. RESULTS: PICP in CSF taken at the start of external CSF drainage (median day 21, range 17-25 days postnatal age) was significantly increased (median 851.5, range 153.5-1944 microg/l) compared with controls (median 136.1, range 33.8-169.5 microg/l). CSF concentrations of PICP declined until permanent shunt placement (median day 70, range days 41-113). CONCLUSION: In neonates who develop PHHC, significant elevation of PICP concentration in the CSF is present 3-4 weeks after IVH. It reflects the increase of local type I collagen turnover, thereby correlating with manifestation of PHHC.     

Increased total-Tau levels in cerebrospinal fluid of pediatric hydrocephalus and brain tumor patients

Total Tau (t-Tau), hyperphosphorylated Tau (p-Tau(181P)) and beta-amyloid(1-42) in cerebrospinal fluid (CSF) have shown to be markers of neuronal and axonal degeneration in various neurological and neurodegenerative diseases. The aim of this study was to evaluate the influence of the presence of a brain tumor and hydrocephalus on t-Tau, p-Tau(181P) and beta-amyloid(1-42) levels in CSF of pediatric patients. t-Tau, p-Tau(181P) and beta-amyloid(1-42) levels were simultaneously quantified by xMAP technology in 22 lumbar and 15 ventricular CSF samples from newly diagnosed pediatric brain tumor patients and 39 lumbar and 12 ventricular CSF samples from pediatric patients without a brain tumor. t-Tau, p-Tau(181P) and beta-amyloid(1-42) levels in both lumbar and ventricular CSF were not significantly correlated with age. t-Tau levels in lumbar CSF were elevated in brain tumor patients, being especially high in medulloblastoma patients. Lumbar CSF p-Tau(181P) levels were lower in brain tumor patients compared to normal controls. Ventricular levels of t-Tau, p-Tau(181P) and beta-amyloid(1-42) were not significantly different between the brain tumor patients and non-tumor patients, but t-Tau levels were significantly increased in patients with radiological signs of hydrocephalus. Two patients with an infected ventriculo-peritoneal drain also had high CSF t-Tau levels. In conclusion, high t-Tau levels in CSF are found in pediatric patients with a brain tumor, patients with hydrocephalus and patients with a serious CNS infection, reflecting neuronal and axonal damage. Ongoing studies should determine whether these neurodegenerative markers in CSF can be used to monitor neuronal and axonal degeneration in these patients during therapy and long-term follow up.     

Increased cerebrospinal fluid concentrations of soluble Fas (CD95/Apo-1) in hydrocephalus.

BACKGROUND AND AIMS: The ventricular enlargement observed in children with chronically raised intracranial pressure (ICP) causes a secondary loss of brain tissue. In animal studies of hydrocephalus, programmed cell death (apoptosis) has been found as a major mechanism of neuronal injury. One of the regulators of the apoptotic cell death programme is the receptor mediated Fas/Fas ligand interaction. METHODS: The apoptosis regulating cytokines soluble Fas (sFas) and soluble Fas ligand (sFasL) were studied in the cerebrospinal fluid (CSF) of 31 hydrocephalic children undergoing shunt surgery for symptomatic hydrocephalus and 18 controls. RESULTS: High concentrations of sFas were observed in children with hydrocephalus (median 252 ng/ml); in controls sFas was below the detection limit (0.5 ng/ml). sFasL was undetectable in all but one sample. CONCLUSION: High concentrations of sFas in the CSF of children with hydrocephalus suggest intrinsic sFas production, potentially antagonising pressure mediated Fas activation.     

Third ventriculostomy versus cerebrospinal fluid shunt as a first procedure in pediatric hydrocephalus

BACKGROUND: Third ventriculostomy (TV) has been reported to be efficacious for diverse causes of obstructive hydrocephalus in pediatric patients, and preferable to a first CSF shunt (CS) in those eligible. We reviewed the respective failure rates in a prospective cohort of patients at our institution. METHOD: All patients having either TV or CS (i.e ventriculoperitoneal shunt) over the period 1987 to 1997 were prospectively entered into a database. To compare homogeneous patients, only diagnoses of either aqueductal stenosis or tumor were considered. Failure was defined as any subsequent surgical procedure for CSF diversion. Kaplan-Meier curves were constructed to determine survivorship. A multivariable Cox model using time-dependent covariates was constructed. RESULTS: There were 32 TV and 210 CS patients: 14 (44%) and 95 (45%) failed, respectively. TV patients were older (median age = 8.1 vs. 3.6 years) and had a higher incidence of aqueductal stenosis (53 vs. 25%). There was no statistically significant difference between the two procedures based on bivariate analysis (p = 0.87) and on multivariable analysis using the Cox model after adjusting for the potential confounders (p = 0.66, hazard ratio = 1.19, 95% confidence interval = 0.55-2.56). CONCLUSION: Failure from TV is not unlike that of CS when analyzed by survival methods. Larger prospective series are needed to look at specific subgroups who may benefit from TV. Quality of life and clinical outcome measures are also required to analyze the difference between these two procedures.     

Measurement of cerebrospinal fluid output through external ventricular drainage in one hundred infants and children: correlation with cerebrospinal fluid production

OBJECTIVE: Cerebrospinal fluid (CSF) production rates influence shunt design and the care of children with hydrocephalus. Measurement of hourly CSF output through external ventricular drainage (EVD) reflects the CSF production. In the present study, hourly CSF outputs in children with hydrocephalus were measured while they were treated with EVD and correlated with the age, sex and body weight of the patients as well as other clinical parameters. METHODS: One hundred children with hydrocephalus due to various causes had EVD treatment. Twenty-six had EVD on two or three separate occasions; thus, the CSF output measurements were observed and analyzed on the basis of 130 EVDs. The most common reason for EVD treatment was shunt infection (n = 75). The duration of EVDs ranged from 25 to 774 h (mean 269 h). The height of the drip chamber from the mid-head position ranged from 0 to 23 cm (mean 9.8 cm). The hourly CSF output was analyzed according to the patient's age, sex and body weight as well as the presence of CSF infection. RESULTS: The hourly CSF output rapidly increases during the first year of life. By the second year, it reaches 64% of the hourly CSF output of 15-year-old children. The mean hourly output ranged from 0.1 to 26.5 ml/h (mean 8.1 ml/h), with the standard deviation ranging from 0.4 to 10.8 ml/h (mean 5.2 ml/h). A regression analysis indicated that the age and body weight appeared to correlate with the hourly CSF output. Using the natural logarithm of age, body weight and sex, these predictors accounted for 50.9% of the variability in hourly CSF output. The regression equation is as follows: hourly CSF output = 2.78 - 2.23(male = 0, female = 1) + 0.97 log(age in years) + 2.26 log(body weight in kg). R sd = 3.36, R(2) = 0.509. The type of infecting organism and the height of EVD did not influence the overall CSF output. CONCLUSION: The hourly CSF output fluctuates, but the CSF output increases logarithmically with age and body weight. The gender also influences the CSF output, with males having a greater output than females. The data produced by the present study will help us to understand CSF production rates in developing children. They will also help us in the care of children receiving EVD treatment, as well as in selecting and designing shunt systems.