Hydrocephalus

Moch. Dwikoryanto
Neurosurgery Subdiv of Surgical Department
Dr. Soebandi Hospital
Jember
Common story
Hope?
 INTRODUCTION
History of the Procedure:
First described by Hippocrates
Was not treated effectively until the 20th century
Today focus
Pathophysiology
Valve design in shunting
Minimally invasive techniques of treatment

Problem
Hydrocephalus is the abnormal rise in cerebrospinal fluid volume and,
usually, pressure, that results from an imbalance of cerebrospinal fluid
production and absorption
 INTRODUCTION
Frequency:
Unknown
Congenital occurs in 2-5 births per 1000 births

Etiology:
The etiology in congenital cases is unknown.
Few cases (<2%) are inherited (X-linked hydrocephalus)
The most common causes in acquired cases are
Tumor obstruction
Trauma
Intracranial hemorrhage
Infection
 INTRODUCTION

Pathophysiology: subdivided into 3 forms.

Disorders of cerebrospinal fluid production
Rarest form of hydrocephalus.
Choroid plexus papillomas
choroid plexus carcinomas
Disorders of cerebrospinal fluid circulation
Results from obstruction of the pathways of CSF circulation.
This can occur at the ventricles or arachnoid villi.
Tumors, hemorrhages, congenital malformations, infections
Disorders of cerebrospinal fluid absorption
Superior vena cava syndrome
Sinus thrombosis
Cannot be classified clearly
Normal pressure hydrocephalus
Pseudotumor cerebri.
INTRODUCTION
 INTRODUCTION
Clinical:
The various types of hydrocephalus
Age groups.

Acute hydrocephalus
Headache
Gait disturbance
Vomiting
Visual changes
 INTRODUCTION

In infants
Irritability
Poor head control
Parinaud syndrome (upgaze palsy)
Setting sun sign (Parinaud, lid retraction, tonic downgaze)
Sixth nerve palsy
Papilledema
Bulging fontanelles
Dilated scalp veins
Increasing head circumference
Brainstem signs
Coma
Hemodynamic instability
 INTRODUCTION
Normal Pressure Hydrocephalus
Has very distinct symptomatology.
The patient is older
Presents with
Progressive gait apraxia
Incontinence
Dementia
(This triad of symptoms defines normal pressure hydrocephalus)
 INDICATIONS
Most cases of symptomatic hydrocephalus need to be treated
Before permanent neurologic deficits
Before neurologic deficits progress

When an etiologic factor is known,

Treated with temporary measures while the underlying condition is
treated
Ventriculostomy until a posterior fossa tumor is resected
Lumbar punctures in a neonate with intraventricular hemorrhage until
the blood is absorbed and normal cerebrospinal fluid absorption
resumes
 CONTRAINDICATIONS
Hydranencephaly
Surgery would not affect the outcome
Ventriculomegaly of senescence
Does not have the symptom triad
Ex vacuo hydrocephalus
Lost cerebral tissue with cerebrospinal fluid.
Technically is not hydrocephalus.
Arrested hydrocephalus
Neurologic status of the patient is stable
Stable ventriculomegaly.
Benign hydrocephalus
Neonates and young infants
Asymptomatic, and head growth is normal.
CT scan shows mildly enlarged ventricles and subarachnoid spaces.
 WORKUP

Imaging Studies:

CT scan of the head

Degree of ventriculomegaly
Etiology
Helps with operative planning
With contrast
Infection
Tumors causing obstruction
Pseudotumor cerebri, the CT scan usually are normal.
 WORKUP
MRI scan of head
Congenital cases of hydrocephalus
Associated brain anomalies
Corpus callosum agenesis
Chiari malformations
Disorders of neuronal migration
Vascular malformations
Tumors (midbrain tectal gliomas)
T2-weighted transependymal flow of CSF
 WORKUP

MRI scan of head

 WORKUP

MRI scan of head

 WORKUP
Fetal and neonatal cranial ultrasound
Monitoring ventricular size
Intraventricular hemorrhage in the neonatal ICU setting
Certainly, prior to treatment, perform other imaging studies
 WORKUP
Diagnostic Procedures:
Lumbar puncture
Measure intracranial pressure
Rule out an obstruction
A diagnostic high-volume lumbar puncture in NPH can assist in making
decisions regarding shunting.
Spinal fluid can show the type and severity of infection
 TREATMENT
Medical therapy
Temporizing measure
In transient conditions
Sinus occlusion
Meningitis
Neonatal intraventricular hemorrhage

Acetazolamide (25 mg/kg/d in 3 doses)

Careful monitoring of respiratory status and electrolytes
Treatment beyond 6 months is not recommended.
Furosemide (1 mg/kg/d in 3 doses)
Electrolyte balance and fluid balance need to be monitored
 TREATMENT
Lumbar punctures
In neonates recovering from intraventricular hemorrhage,
Serial lumbar punctures can resolve hydrocephalus in some cases.
If possible, this is the preferred method of treatment

Removal of the underlying cause

Resolves hydrocephalus in most cases.
 TREATMENT
Surgical therapy:
CSF diversion has increased in frequency, so aware pitfalls of the procedure.
Recently, interest in third ventriculostomies

Preoperative details:
Make every effort to identify the cause of hydrocephalus
Make every effort to treat hydrocephalus medically
Do not consider diversion in patients with infection or high cerebrospinal fluid
protein (>150 mg/dL).
Obtain some idea of brain compliance in order to select the optimum valve
pressure and decide if the pressure-programmable valve should be used.
Use one dose of preoperative prophylactic antibiotics.
 TREATMENT
Intraoperative details
Third ventriculostomy:
Obstructive cases normal or near normal spinal fluid absorptive
capacity
Use a blunt instrument to penetrate the floor of the third ventricle
Sharp instruments or lasers can cause vascular injury.
Leaving a clamped drain in place postoperatively might be
prudent.
The burr hole placed on the coronal suture allows a straight
trajectory to the foramen of Monro.
Stereotactic guidance is not needed if endoscopic techniques are
used.
 TREATMENT
Ventriculoperitoneal shunting
The most common procedure for cerebrospinal fluid
diversion
The abdomen should be able to absorb fluid
The ventricular catheter can be placed more reliably from
the coronal approach
Some surgeons still prefer parietooccipital catheters
The proximal catheter tip should lie anterior to the choroid
plexus in the frontal horn of the lateral ventricle
 TREATMENT
Ventriculoatrial shunting:
This procedure usually is the first choice for patients who
are unable to have abdominal distal catheters (eg, multiple
operations, recent abdominal sepsis, known malabsorptive
peritoneal cavity)
The procedure carries more risk
Long-term complications are more serious (eg, renal
failure, great vein thrombosis)
Fluoroscopic guidance is necessary to prevent catheter
thrombosis (short distal catheter) or cardiac arrhythmias
(long distal catheter)
 TREATMENT
Ventriculopleural shunting
Reserve this procedure for patients with failed peritoneal and atrial
shunts
Torkildsen shunts or internal shunts
Straight tubes that communicate to cerebrospinal fluid spaces without
a valve
Their effectiveness and long-term efficacy are not proven
Lumboperitoneal shunts
Communicating hydrocephalus, especially if ventricles are small
Pseudotumor cerebri is the classical indication of this method of
shunting
 TREATMENT
Postoperative details:
ICU observation after third ventriculostomy
In patients with high brain compliance, gradual assumption of the
upright position and slow mobilization may reduce the incidence of
early subdural hematoma formation
Plain radiographs of the entire hardware system confirm good position
and serve as excellent baseline studies for the future
Wounds should remain dry for at least 3 days postoperatively, until
epithelialization has occurred
In patients with pleural shunts, perform an early postoperative chest
radiograph to ensure adequate absorption of fluid. Large effusions can
occur in short periods, and respiratory problems can ensue.
 TREATMENT

Follow-up care
Shunt placement
Remove stitches by 2 weeks postsurgery
Perform CT scan at 2-4 weeks postsurgery
Valve patency
Any infection over tract line
Check distal tubing length with plain radiographs
when the child grows
Translocation (rare)
 TREATMENT

Follow-up care
Clinical progresses
Monitor all children with shunts every 6-12 months
Carefully monitor head growth in infants.
35 cm at bird
Incr 2 cm/m until 3 months
Incr 1 cm/m 3-6 months
Incr 0.5 cm/m 6-9 months
Appropriate specialists should carefully assess child
development
Pseudotumor cerebri, visual acuity and fields should be
monitored by the appropriate specialist
Ventriculoperitoneal shunting
 Ventriculoperitoneal shunting

Standard shunt valve

 Ventriculoperitoneal shunting

Programmable Shunt System

 Ventriculoperitoneal shunting

3 areas
 Ventriculoperitoneal shunting

Kocher point
 Ventriculoperitoneal shunting

Keen point
 Ventriculoperitoneal shunting

Keen point
 Ventriculoperitoneal shunting

Keen point
Ventriculoperitoneal shunting
Ventriculoperitoneal shunting
Ventriculoperitoneal shunting
Ventriculoperitoneal shunting
Ventriculoperitoneal shunting
 COMPLICATIONS
The most common complications differ depending
on
The type of shunt
Underlying pathophysiology
Ie :
Ileus, catheter in brain, subdural hematoma, brain hematoma, neck
hematoma, skin perforation, lung injury, bowel injury,
peritonitis, obstruction, infection, disconnection, exposed catheter,
translocation
 COMPLICATIONS
Infection is the most feared (young age group)
Occur within 6 months of the original procedure.
Common infections are staphylococcal
More frequently in neonates is Escherichia coli.
Infected shunts need to be removed the CSF needs to
be sterilized a new shunt needs to be placed
Treatment of infected shunts with antibiotics alone is not
recommended
COMPLICATIONS
 COMPLICATIONS
Subdural hematomas
Occur almost exclusively in adults and children
with completed head growth
Incidence of subdural hematomas can be reduced
by slow postoperative mobilization
This allows for brain compliance reduction
The treatment is drainage and
May require temporary occlusion of the shunt
 COMPLICATIONS
Shunt failure
Due to suboptimal proximal catheter placement
Occasionally, distal catheters fail
Suspect infection if the distal catheter is obstructed with debris
Abdominal pseudocysts are synonymous with low-grade shunt
infection.

Overdrainage
Common in lumboperitoneal shunts
Manifests with headaches in the upright position
A self-limiting process
Revision to a higher-pressure valve or a different shunt system
 COMPLICATIONS
Slit ventricle syndrome
Brain compliance is unusually low
Mostly occurs in prior ventriculitis or shunt infection
The patient may develop high pressures without
ventricular dilatation.
The slit ventricle syndrome does not imply overdrainage
Symptoms usually high pressure rather than low pressure.
Predispose the patient to a higher incidence of ventricular
catheter failure.
 REDUCING of COMPLICATIONS

Strict indication
Procedure standardization
Operating room management
Prophylaxis choice
Valve choice type, opening pressure
Time consuming less 25 minutes
No more 4 persons inside OR
 OUTCOME and PROGNOSIS

In general, outcome is good

Especially in early treatment
A typical patient should return to baseline after shunting
The neurological function of children is optimized with shunting
Normal pressure hydrocephalus
gait and incontinence respond to shunting
dementia responds less frequently
Often, various other neurological abnormalities associated
with hydrocephalus are the limiting factor in patient recovery.
Examples are migrational abnormalities and post infectious
hydrocephalus.
 FUTURE and CONTROVERSIES

Hydrocephalus research and treatment have

advanced tremendously in the last 20 years
Development of new shunt materials
Programmable valve technology
Current research to eliminate the need for shunting
Transplantation of tissue
Third ventriculostomies
Aqueductoplasty
Thank you

Welcome to Dragon Fruit Village