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.     

Delayed endoscopic intraventricular hemorrhage (IVH) removal and endoscopic third ventriculostomy may not prevent consecutive communicating hydrocephalus if IVH removal was insufficient.

OBJECT: The aim of this study was to investigate whether delayed endoscopic treatment of intraventricular hemorrhage (IVH) can prevent consecutive communicating hydrocephalus. METHODS: A retrospective series of 9 patients with IVH caused by intracerebral hemorrhage (ICH) who were treated with external ventricular drainage (EVD) or endoscopic IVH removal and endoscopic third ventriculostomy (ETV) was studied in our institute. Five of these patients who had previously been treated a year before in our institute with the installation of a flexible endoscope, were treated with EVD alone on admission. Of the other patients, three received endoscopic removal of IVH and ETV and, after a one week, EVD placement, and the final patient underwent endoscopic IVH removal and ETV one day after onset. RESULTS: Three of the patients treated with EVD alone were fitted with the EVD for 8, 11 and 16 days, and 2 patients were fitted with the EVD until they died. No patients treated with EVD alone required shunt placement. In contrast, of the 4 patients treated endoscopically, EVD was placed totally for 0, 6, 9, and 22 days for each patient, among whom 2 patients required shunt placement. CONCLUSIONS: Delayed endoscopic IVH removal and ETV might not prevent consecutive communicating hydrocephalus if IVH removal was insufficient.     

The use of ventriculoperitoneal shunts for uncontrollable intracranial hypertension without ventriculomegally secondary to HIV-associated cryptococcal meningitis

BACKGROUND: The risks associated with implanting a cerebrospinal fluid (CSF) shunt in immunocompromised patients with ongoing CSF infection have historically discouraged surgeons from implanting CSF shunts in patients with HIV and cryptococcal meningitis. However, this patient population often requires frequent lumbar punctures to manage elevated intracranial pressure (ICP) secondary to cryptococcal infection. To date, only 7 cases of ventriculoperitoneal (VP) shunting for the treatment of intracranial hypertension in patients with HIV-associated cryptococcal meningitis have been reported. Few of these reports have included outcomes more than 3 months postsurgery. It remains unclear if VP shunts are an effective long-term treatment of intracranial hypertension in this patient population. CASE DESCRIPTIONS: Two patients with HIV/AIDS (CD4 counts of 8 and 81 cells/mm(3)) presented with altered mental status, visual changes, florid cryptococcal meningitis, and elevated ICP (>500 mm CSF) without evidence of hydrocephalus on computed tomography scan. Both patients experienced rapid reversal of symptoms with external lumbar CSF drainage, and remained lumbar drain-dependent after 2 weeks of amphotericin B and flucytosine therapy. Despite evidence of unresolved cryptococcal meningitis, each patient underwent implantation of a VP shunt without complication and was discharged on lifetime fluconazole therapy. They remained asymptomatic at 12 and 16 months after surgery without evidence of shunt infection or malfunction. CONCLUSION: Patients with intracranial hypertension and HIV-associated cryptococcal meningitis who cannot tolerate cessation of external lumbar CSF drainage or frequent lumbar punctures may be considered for VP shunt placement despite severe immunosuppression and persistent CSF cryptococcal infection.     

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.     

Technical Note: External Cerebrospinal Fluid (CSF) Drainage by Percutaneous Needle Punction in Newborn Children

Summary  External drainage of CSF in children is indicated in acute hydrocephalus e.g. after intraventricular bleeding or infection. In these cases the drainage has to remain in place until physiological CSF circulation is restored or an internal shunt can be inserted. External drainage is mostly performed using a silicon catheter connected to a plastic bag. An external CSF drainage left for several days in situ bears an increasing risk of bacterial infection. In these cases a metal needle minimizes the risk of ventriculitis.  For prevention of accompanying infection we implanted a Cytocan^R port needle with a 20 G diameter in 7 infants. The needle is easily inserted with low risk of complications. By its plastic top angulated at 90° to the needle the system can be fixed to the skin very safely by suture or tape.  With this system neither an implantation related intracerebral haemorrhage nor an accompanying ventriculitis was encountered. In two cases a pre-existing ventriculitis was cured by this needle drainage and antibiotic treatment. In five cases an acute hydrocephalus after intraventricular haemorrhage was drained by the port needle system.     

Risk of infection after cerebrospinal fluid shunt: An analysis of 884 first-time shunts

Summary Postoperative infections are major complications of cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus and other conditions with obstructed CSF circulation. In a retrospective study 884 first-time shunted patients with hydrocephalus operated on in the years 1958–1989 were investigated with special reference to the infection rate and to the influence of the following variables: time period, age of the patient, education of the neurosurgeon, length and time of the operation and the exact placement of the distal drain.The overall infection rate for all implanted CSF shunts was 7.4% (5.7–9.3%) and the acute rate of infection was 6.2% (4.6–7.9%). The rate of infection was virtually constant for all variables with the exception of the education of the neurosurgeon. Neurosurgical trainees particularly had a significantly higher rate of infection.Shunt infection is still a major complication. The infection rate has not declined in recent decades. It is not possible to relate any main cause to the infection rate. The literature recommends removal of the infected shunt combined with antibiotics. The use of prophylactic antibiotics is still controversial. No prospective, double-blind studies, including a sufficiently large number of patients to evaluate this issue, exist today.     

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.     

A flexible metal ventricular catheter for treatment of complicated and protracted infections of the cerebrospinal fluid spaces: Preliminary experiences

Summary In the management of shunt infection, the use of ventricular catheters made of silicone rubber for the temporary external drainage of cerebrospinal fluid (CSF) is general practice. However, the eradication of the primary source of infection may be hindered by the affinity of bacteria to silicone-based material. Compared to silicone catheters, a metal drainage device for temporary ventriculostomy appears to offer more favourable conditions for successful eradication of the infection. Since metal needles cannot be implanted permanently and since their screw-type fixation precludes attachment to the skulls of infants or small children, we developed a flexible metal catheter. This catheter was used exclusively for the treatment of particularly serious or chronic infections of the CSF spaces. The catheter is made of implantation steel and consists of a corrugated tube that renders it flexible. Cerebrospinal fluid drains into a receptable bulb at the tip of the tube. Tubing of other materials may be connected to the end of the metal catheter for either external or internal drainage. It was implanted as a temporary and later permanent CSF drainage in 7 male patients aged from 4 to 60 years, who suffered from chronic, recurrent ventriculitis (n = 5) with an average of 7 previous surgical revisions, as well as from complex infections (n = 2; basal tuberculous meningitis, brain abscess). The infections were successfully eliminated in 6 patients. In the remaining patient, the metal catheter for external ventriculostomy had to be removed after 4 days due a leakage of CSF; it was replaced by a silicone catheter and later on by a needle drainage. Other complications, such as secondary infection or intracerebral haemorrhage, did not occur. The average duration of external CSF drainage via the flexible metal catheter was 27 days (range 4–50 days). In 4 patients, the CSF drainage was converted to a permanent ventriculoperitoneal shunt using a new flexible metal catheter. At the time of post-operative follow-up examination (average = 34 weeks), all shunts were functioning and there was no evidence of infection. In cases of especially complicated and protracted CSF infections, the flexible metal ventricular catheter is a promising device for treatment.     

Endoscopic coagulation of the choroid plexus using the Nd:YAG laser: initial experience and proposal for management

Although most patients with hydrocephalus are treated effectively with ventriculoperitoneal shunts, a small group fails to respond to diversion procedures. In some patients within this group, hydrocephalus may be caused in part by the overproduction of the cerebrospinal fluid (CSF). In other patients, previous shunt infections may limit the ability of the peritoneum to absorb fluid, and patient response to a ventriculoperitoneal shunt may be improved by reducing CSF production. We discuss a case of a 29-month-old hydrocephalic infant with a ventriculoperitoneal shunt who had ascites. Computed tomography showed bilateral symmetrical enlargement of the choroid plexus. Repeated cultures of the CSF and shunt tubing were sterile, and the daily production of the CSF exceeded 1000 ml. Therapy with acetazolamide decreased the CSF output temporarily, but it was discontinued after serious electrolyte abnormalities occurred. The endoscopic coagulation of the choroid plexus with a neodymium:YAG laser transmitted through a flexible quartz fiber decreased CSF production effectively. This procedure may be useful in a variety of clinical conditions associated with hydrocephalus or with other intraventricular lesions.     

Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage

OBJECT: In this study the authors evaluate the safety, efficacy, and indications for endoscopic third ventriculostomy (ETV) in patients with a history of subarachnoid hemorrhage or intraventricular hemorrhage (IVH) and/or cerebrospinal fluid (CSF) infection. METHODS: The charts of 101 patients from seven international medical centers were retrospectively reviewed; 46 patients had a history of hemorrhage, 42 had a history of CSF infection, and 13 had a history of both disorders. All patients experienced third ventricular hydrocephalus before endoscopy. The success rate for treatment in these three groups was 60.9, 64.3, and 23.1%, respectively. The follow-up period in successfully treated patients ranged from 0.6 to 10 years. Relatively minor complications were observed in 15 patients (14.9%), and there were no deaths. A higher rate of treatment failure was associated with three factors: classification in the combined infection/hemorrhage group, premature birth in the posthemorrhage group, and younger age in the postinfection group. A higher success rate was associated with a history of ventriculoperitoneal (VP) shunt placement before ETV in the posthemorrhage group, even among those who had been born prematurely, who were otherwise more prone to treatment failure. The 13 premature infants who had suffered an IVH and who had undergone VP shunt placement before ETV had a 100% success rate. The procedure was also successful in nine of 10 patients with primary aqueductal stenosis. CONCLUSIONS: Patients with obstructive hydrocephalus and a history of either hemorrhage or infection may be good candidates for ETV, with safety and success rates comparable with those in more general series of patients. Patients who have sustained both hemorrhage and infection are poor candidates for ETV, except in selected cases and as a treatment of last resort. In patients who have previously undergone shunt placement posthemorrhage, ETV is highly successful. It is also highly successful in patients with primary aqueductal stenosis, even in those with a history of hemorrhage or CSF infection.     

Cell index – a new parameter for the early diagnosis of ventriculostomy (external ventricular drainage)-related ventriculitis in patients with intraventricular hemorrhage?

Summary Temporary intraventricular catheters for managing acute obstructive hydrocephalus caused by intraventricular haemorrhage carry a high risk of developing ventriculostomy-related ventriculitis (VRV). The aim of this prospective study was to validate a new parameter for the early detection of an intraventricular infection.Methods. Patients with external ventricular drainage due to intraventricular haemorrhage were enrolled in this prospective study. Leucocytes and erythrocytes in cerebrospinal fluid (CSF) and peripheral blood as well as bacteriological and chemical analysis of both were examined daily. The ratio of leucocytes to erythrocytes in CSF and leucocytes to erythrocytes in peripheral blood was calculated (so called cell index (CI)) and these values were compared with the conventionally diagnosed drain-associated ventriculitis. Furthermore, the CI values of the non-ventriculitis and ventriculitis group were compared using the t-test with adjustment for unequal variances (Welch test).Results. Thirteen patients with an external ventricular drainage (EVD) expected to be in place for more than seven days were enrolled. Seven patients developed a bacteriologically proven VRV (time 0) within 12 days (mean 8.57). Diagnosis of VRV by CI was possible up to 3 days (mean 2.28) prior to conventional diagnosis. P values (Welch test) showed a significant difference on days –3 (P=0.03), –2 (P=0.03) and –1 (P=0.012) – i.e. 3, 2 or 1 day, respectively, prior to the time point when the CSF culture grew staphylococci –, when compared with the mean cell indices of the controls, and a highly significant difference on time 0 (P<0.001).Conclusion. The calculated CI allows the diagnosis of nosocomial VRV in patients with intraventricular haemorrhage at a very early point of time.     

Shunt malfunction in relation to shunt infection

Summary Ventriculo-peritoneal shunt malfunction may be caused by shunt infection which may not be clinically apparent as the cause of the malfunction by standard diagnostic criteria. This suggests that the real incidence of infected shunts might be higher than previously suspected. In order to study the relationship between infection and shunt malfunction, we followed a protocol over five years (54 V-P shunts) consisting of (1) removal of the malfunctioning shunt and replacement in the same surgical procedure with a new one or institution of an external ventricular drainage for 8 days (if there were clear signs of infection), (2) culturing of CSF and every part of the removed shunt, and (3) intravenous antibiotic treatment (Vancomycin 1g./12h + Ceftriaxone 1g./12h) for five days after the new V-P shunt had been inserted. In those cases in which an external ventricular drainage had been placed, its tip and a portion of the new V-P shunt were also cultured. The results showed that although CSF cultures were negative in 49/54 cases (90.7%), cultures of the removed shunts were positive in 32/54 (59.2%), most of them (21/32, 65.6%) for Staphylococcus coagulase negative organisms.The CSF samples obtained by puncturing the reservoir on admission to Hospital were positive only in 5 out of 54 cases (9.2%), only in those showing clinical features of infection. In the remaining cases, 27 out of 54 (50%) the CSF cultures were negative but the shunt cultures proved positive and required further treatment.For the newly inserted shunts (173) CSF was collected through the shunt during the surgical procedure, and a small piece of the extra-tube from the ventricular and from the peritoneal catheter were obtained and cultured. All the six shunts (6/173, 3.4%) that showed positive cultures after insertion had to be replaced within a period of three to four weeks due to malfunction (range 26±7 days), indicating that the systematic culture of CSF and tubing helps to predict which shunts will soon need to be replaced due to infection.We conclude that CSF culture alone does not rule out infection in cases of shunt malfunction. The percutaneous CSF obtained from the shunt reservoir on admission is particularly prone to show negative cultures even when the shunt is colonized by bacteria.     

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.     

Endoscopic observations of blocked ventriculoperitoneal (VP) shunt: a step toward better understanding of shunt obstruction and its removal

Abstract Objectives. Most of our understanding of ventriculoperitoneal (VP) shunt blockage (ventricular end) is based on in vitro studies of blocked VP shunts. Not much information is available regarding the in vivo changes that occur in the tube and in the surrounding ventricle. The primary aim of our study was to observe and analyse these changes, directly, through the endoscope, in patients with blocked shunts undergoing an endoscopic third ventriculostomy (ETV). Based on these findings, we have also suggested criteria for safe removal of the VP shunt tube following ETV. Material and methods. ETV was performed with standard technique in patients with blocked VP shunt. The ventricular end of the shunt tube was inspected through the endoscope, for changes in ventricle linings as well as in the shunt tube. These changes were correlated with the age of the patient, etiology of HC, type or make of the shunt tube, duration of shunt placement to ETV and the CSF findings. Results. Fifty-three patients of blocked VP shunt underwent ETV from July 2006 to April 2010. Thirty patients had Chhabra (CH) V P Shunt (Surgiwear, India) and 23 had ceredrain (CD) shunt (Hindustan Latex, India). The age of the patients ranged from 2 months to 60 years (mean - 13.33 years.). Various causes of hydrocephalus (HC) included congenital hydrocephalus (aqueductal stenosis) in 18 patients, post-meningitis hydrocephalus (PMH) in 32 cases, neuro-cysticercosis (NCC) in 2 patients and intraventricular haemorrhagic (IVH) in 1 patient. Clinical and radiological improvement occurred in 33 (62.21%), and 24 (45%) patients, respectively. Freedom from shunt was attained in 20 (38%) patients. The changes around the shunt tube were seen in 41 (77%). Hyperaemia and neovascularised ependyma was seen in 20 (37%) and 15 (28%) patients. Encasement of the tube was seen in 41%. Ependymal growth and neovascularised shunt tubes were noticed in 15% each. Choroid plexus blocking the tube was seen in only four cases (7%). VP shunt was revised in 14 patients (26.4%). Patient with infective etiology had more changes (p 相似文献   

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.     

Intracranial hemorrhage associated with stent-assisted coil embolization of cerebral aneurysms: a cautionary report

OBJECT: The introduction of the Neuroform microstent has facilitated the embolization of complex cerebral aneurysms, which were previously not amenable to endovascular therapy. Typically, the use of this stent necessitates the administration of dual antiplatelet therapy to minimize thromboembolic complications. Such therapy may increase the risk of hemorrhage in patients who require concurrent external ventricular drainage and/or subsequent permanent cerebrospinal fluid diversion. METHODS: The authors' neurosurgical database was queried for all patients who underwent stent-assisted coil embolization for cerebral aneurysms and who required an external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt placement for management of hydrocephalus. RESULTS: Thirty-seven patients underwent stent-assisted coil embolization for intracranial aneurysms at the authors' institution over a recent 2-year period. Seven of these patients required placement of an EVD and/or a VP shunt. Three of the 7 patients suffered an immediate intraventricular hemorrhage (IVH) associated with placement or manipulation of an EVD; 1 experienced a delayed intraparenchymal hemorrhage and an IVH; 1 suffered an aneurysmal rehemorrhage; and the last patient had a subdural hematoma (SDH) that resulted from placement of a VP shunt. This patient required drainage of the SDH and exchange of the valve. CONCLUSIONS: The necessity of dual antiplatelet therapy in the use of stent-assisted coil embolization increases the risk of intracranial hemorrhage and possibly rebleeding from a ruptured aneurysm. This heightened risk must be recognized when contemplating the appropriate therapy for a cerebral aneurysm and when considering the placement or manipulation of a ventricular catheter in a patient receiving dual antiplatelet therapy. Further study of intracranial procedures in patients receiving dual antiplatelet therapy is indicated.     

Clinical features in patients requiring reoperation after failed endoscopic procedures for hydrocephalus.

The aim of this study was to clarify the clinical features of patients at risk of secondary obstruction following endoscopic fenestration. Clinical notes and endoscopic findings for 15 patients treated with endoscopic procedures were retrospectively reviewed. Endoscopic third ventriculostomy (ETV) was performed as initial treatment in 4 patients with non-communicating hydrocephalus, including a neonate with myelomeningocele, and as an alternative to shunt revision in 4 patients. Two patients with non-communicating hydrocephalus caused by tumor or arachnoid cyst were also managed with third ventriculostomy. Four patients with loculated hydrocephalus underwent endoscopic septostomy. A child with an isolated fourth ventricle was treated with endoscopic aqueductoplasty. Of the 15 patients undergoing endoscopic procedure, 4 required reoperation. Of the 10 patients treated with ETV, only the neonate with myelomeningocele required a ventriculoperitoneal shunt because of failure of the initial procedure. Of the 4 patients treated with endoscopic septostomy, 2 children with loculated hydrocephalus following intraventricular hemorrhage (IVH) underwent a second septostomy. In a patient with an isolated fourth ventricle following posthemorrhagic hydrocephalus, recurrence was noted 8 months after the initial procedure. He underwent a second procedure using a stent implanted into the aqueduct to maintain CSF circulation. Sufficient stomal size or implantation of a stent may be required in the under-2-year age group with hydrocephalus accompanied by IVH and associated with myelomeningocele, in whom the risk of secondary obstruction may be high.     

Hollow mandrin facilitates external ventricular drainage placement

Summary Background. Placement of ventricular catheters is a routine procedure in neurosurgery. Ventricle puncture is done using a flexible ventricular catheter stabilised by a solid steel mandrin in order to improve stability during brain penetration. A correct catheter placement is confirmed after removing the solid steel mandrin by observation of cerebrospinal fluid (CSF) flow out of the flexible catheter. Incorrect placement makes further punctures necessary. The newly developed device allows CSF flow observation during the puncture procedure and in addition precise intracranial pressure (ICP) measurement.Method. The developed mandrin is hollow with a blunt tip. On one side 4–5 small holes with a diameter of 0.8 mm are drilled corresponding exactly with the holes in the ventricular catheter, allowing CSF to pass into the hollow mandrin as soon as the ventricle is reached. By connecting a small translucent tube at the distal portion of the hollow mandrin ICP can be measured without loss of CSF. The system has been used in 15 patients with subarachnoid haemorrhage (SAH) or intraventricular haemeorrhage (IVH) and subsequent hydrocephalus.Findings. The new system improved the external ventricular drainage implantation procedure. In all 15 patients catheter placement was correct. ICP measurement was easy to perform immediately at ventricle puncture. In 4 patients at puncture no spontaneous CSF flow was observed, therefore by connecting a syringe and gentle aspiration of CSF correct placement was confirmed in this unexpected low pressure hydrocephalus. Otherwise by using the conventional technique further punctures would have been necessary.Conclusions. Advantages of the new technique are less puncture procedures with a lower risk of damage to neural structures and reduced risk of intracranial haemorrhages. Implantation of the ventricular catheter to far into the brain can be monitored and this complication can be overcome. Using the connected pressure monitoring tube an exact measurement of the opening intracranial pressure can be obtained performed without losing CSF.     

脑积水脑室-腹腔分流术后并发颅内感染的原因与防治措施分析

目的探讨脑积水脑室-腹腔分流术后患者并发颅内感染的原因与防治措施。方法对139例接受脑积水脑室-腹腔分流术患者的临床资料进行回顾性分析,总结患者术后颅内感染的发生情况,探讨其原因和防治措施。结果脑积水脑室-腹腔分流术后患者并发颅内感染发生率为3.60%(5/139),以早期感染为主,占80%(4/5)。结论脑积水脑室-腹腔分流术后患者并发颅内感染原因较多,以术中操作原因为主,应采取多种措施预防以降低感染发生率。