Computed tomography of the brain in the diagnosis of and prognosis in normal pressure hydrocephalus

Summary Thirty-eight patients with normal pressure hydrocephalus were examined by CT before and after a ventriculo-peritoneal shunt operation. Evans ratio, periventricular hypodensity and width of hemispheric sulci, sylvian fissures, cella media, temporal horns and third and fourth ventricle were examined. Twenty-eight patients improved after the operation while 10 were unchanged (non responders). Those patients who improved had more often enlarged third ventricle, enlarged temporal horns and normal sylvian fissures than those who did not improve. No single CT parameter or combination of CT parameters alone could identify responders and non-responders. The ventriculo-peritoneal shunt operation reduced ventricular size (Evans ratio, cella media width), abolished periventricular hypodensity and reduced width of the temporal horns and third ventricle in both responders and non-responders. Reduction of the width of the third ventricle correlated to clinical improvement.     

Prediction of Cerebral Ischemic Tolerance During Carotid Cross-clamping by Angiographic Criteria

OBJECTIVE: To evaluate the prognostic value of angiographic criteria and internal carotid artery (ICA) stump pressure for shunt placement in carotid surgery under local anaesthesia. DESIGN: Prospective clinical trial at a university hospital. MATERIALS AND METHODS: In 120 patients a cerebral angiography was initiated before undergoing carotid surgery. Seventy-five percent of the patients were neurologically asymptomatic, 13% had transient ischaemic attacks and 12% suffered from previous strokes. The operation was exclusively performed under local anaesthesia and prior to cross-clamping the ICA stump-pressure was measured. A shunt was inserted only if hemispheric symptoms or unconsciousness occurred independent of the angiographic findings or stump pressure. RESULTS: In 23% (27/120) a shunt became necessary and significantly (p<0.001) more often when there was a cross-flow towards the contralateral hemisphere (12/20=60%) or if the contralateral ICA was occluded (9/13=69%). The sensitivity for not needing a shunt in case of cross-flow towards the side of operation was 91% (52/57) whereas the specificity was 35% (22/63). ICA stump-pressure was significantly reduced in patients requiring a shunt (31 mmHg) compared to those not needing a shunt (53 mmHg) (p<0.001), but no definitive threshold value was found determining the need for shunting. Intraoperatively, no persistent neurological complication developed. CONCLUSIONS: Angiographic cross-flow was a good, but not perfect predictor for the need of an intraoperative shunt.     

Bi-directional Glenn shunt in presence of anomalous pulmonary venous connection; modified Bi-directional Glenn shunt

Bi-directional Glenn shunt is a common procedure in a patient with functional single ventricle on the way to Fontan completion. The procedure becomes challenging when there is an associated anomalous pulmonary venous connection to the superior vena cava. We describe an infant with an anomalous pulmonary venous connection high up in the superior venacava, which was managed surgically by performing an anastomosis between the superior venacava and pulmonary artery leaving the anomalous venous drainage intact.     

重型脑外伤后脑积水（附69例报告）

目的 分析重型脑外伤后脑积水的诊治经验，方法 统计本院５年来收治脑外伤后脑积水例数，发病率，主要表现及治疗效果。结果 轻度脑积水２６例，保守治疗１－３个月治愈１８例，８例积水加重，中～重度脑积水５１例，２例行脑室心房分流术４９例行脑室腹腔分流术，治愈３７例，好转１２例，死亡２例，死于心肺功能衰竭。结论 提高对本病的认识，及时ＣＴ检查及妥善处理，可降低重型脑外伤的死残率。     

224. Langzeitergebnisse nach portocavalen Anastomosen bei Patienten mit massiver Oesophagusvaricenblutung

Zusammenfassung Vom 1.5.1977 bis 31.12.1978 wurden 21 Warren-Shunts angelegt. Unselektiertes Krankengut mit 4 Child A-, 14 Child B-, 3 Child C-Fällen. Postoperative Letalität 23,8%. (n = 5), jedoch nur ein technischer Fehler. Postoperative Komplikationen: Rezidivblutung in 19,04%; keine Pankreatitis. Kontrollangio (100%.) : nur bei 1 Patienten hepatofugale Strömung; Splenomegalieabnahme in 66,6%. Nur bei 1 Patienten klinische Zeichen einer Encephalopathie. 87,5%. postoperativ arbeitsfähig. Conclusio: keine negative Beeinflussung der Letalitätsrate durch diese Shunt-Variante. Portale Leberperfusion bleibt erhalten. Encephalopathierate nur 6,25 %. Spätthrombosen selten (6,25 %). Umwandlungsmöglichkeit in einen PC-Shunt bleibt erhalten.     

108. Möglichkeiten und Grenzen der Gefäßdiagnostik mittels CT

Zusammenfassung Bei 16 Patienten wurde ein temporärer Shunt mit antithrombogener Innenfläche (TDMAC Heparin) bei Operation an der Aorta descendens benutzt. Die Eingriffe erfolgten wegen frischer traumatischer Aortenruptur (5), posttraumatischen Aneurysmen (2), dilatierender chronischer Aortendissektion (4), arte riosklerotischen Aneurysmen (3), Aneurysmas nach Isthmusstenosenplastik (1) und Aneurysmas bei PDA. Bei den überlebenden Patienten (13) trat einmal eine Paraplegie mit partieller Rückbildung auf, andere ischämische Organschäden konnten verhindert werden. Die Vorteile des Shunts werden in einer vereinfachten intraoperati ven Kreislaufkontrolle und in der weitgehenden Verhütung ischämiebedingter Organkomplikationen gesehen.     

Infantile subdural fluid collection: diagnosis and postoperative course

The authors reviewed 47 cases of infantile subdural fluid collection with regard to diagnosis and postoperative course after placement of a subdural-peritoneal shunt. CT scan with contrast enhancement proved to be an important diagnostic modality, showing vessels in the subarachnoid space as high-density spots. Utilizing this technique, we were able to differentiate the following varieties of fluid collection: (1) subdural fluid collection, in which enhancing vessels were seen on the brain surfae, (2) subarachnoid fluid collection, in which vessels were on the inner table of the cranium, and (3) coexistence of subdural and subarachnoid fluid collections, in which vessels were between the inner table of the cranium and the brain surface. The postoperative course of subdural fluid collection was characterized as follows: (1) the subdural fluid collection decreased first, with increased subarachnoid fluid collection; (2) the subarachnoid fluid collection remained after the disappearance of subdural fluid collection; and (3) the brain expanded again later. Subdural fluid collection disappeared about 1 month after the shunt operation, which could lead occlusion of the shunt system. Postoperative enlargement of the subarachnoid space was an early indicator of the efficacy of the subduralperitoneal shunt.     

Balloon occlusion portography to diagnose new-onset left hepatic vein thrombosis and widening of an existing wallstent TIPS by palmaz stents for recurrent portal hypertension and variceal bleeding

A 31-year-old man with Child's class A micronodular cirrhosis, left lobe hypertrophy, and a transjugular intrahepatic portosystemic shunt (TIPS) which had been placed 6 months earlier, was admitted for recurrent esophageal bleeding and a portosystemic gradient of 42 mmHg. Balloon occlusion portography documented unsuspected ostial thrombosis of the previously patent left hepatic vein. This was considered the cause of the pressure rise. As it was not possible to insert a second TIPS in parallel, the shunt, stented originally with 10-mm Wallstents, was overdilated to 12 mm, and two 12-mm Palmaz stents were placed coaxially, reducing the portosystemic pressure gradient to 13 mmHg.     

Transjugular intrahepatic portocaval shunt (TIPS) and hepatic vein-to-caval stenting as salvage treatment of portal hypertension secondary to neoplasm

A percutaneous transjugular intrahepatic portocaval shunt (TIPS) was successfully performed using Wallstents in a 53-year-old man with neoplastic disease causing portal hypertension and life-threatening variceal hemorrhage. Shortly after-wards, recurrent hemorrhage was investigated by shunt venography which showed that extrinsic narrowing of the hepatic vein and hepatic vena cava was causing shunt thrombosis. Shunt thrombosis was cleared by balloon occlusion of the shunt and forceful retrograde flushing of thrombus into the portal circulation. The compressed hepatic vein and vena cava were then dilated and stented using Gianturco “Z” stents. Bleeding recurred 3 months later due to focal narrowing within the shunt which possibly was due to intimal proliferation. Repeat dilatation and placement of a coaxial Palmaz stent again relieved portal hypertension. Creation of a TIPS for portal hypertension secondary to neoplasm can produce valuable palliation. Complete assessment of hepatic vein and vena cava patency is required to ensure shunt function.     

Craniofacial growth in shunt-treated hydrocephalics: a four-year roentgenocephalometric follow-up study

The craniofacial growth of 24 shunt-treated hydrocephalics aged 5–15 years was evaluated over a 4-year period, by comparing changes in linear and angular cephalometric variables with those of an age- and sexmatched control group. The main findings were increased calvarial thickness, increased cranial base flexure, superior displacement of the sella, and a tendency for the gonial angle to remain more obtuse in the shunt-treated patients. As craniofacial growth in the latter differed only slightly from that observed in the controls, the deviations in facial morphology observed in a previous cross-sectional study of shunt-treated hydrocephalics can be taken to represent a long-term effect of the shunt treatment.