MASSIVE INTRACRANIAL FLUID COLLECTION

8/7/2019 MASSIVE INTRACRANIAL FLUID COLLECTION

1/29

MASSIVE INTRACRANIAL

FLUID COLLECTION

-hydrocephalus-

BY: Aiza Qen S. De Monteverde


2/29

OBJECTIVES:

To define Hydrocephalus, its types,causes, diagnostics and treatment

Points on how to assesshydrocephalus

Awareness of signs and symptoms ofvp shunt malfunction

Points on medical and surgicalmanagement of hydrocephalus andnursing interventions


3/29

DESCRIPTION:

-Is an imbalance of CSF absorption

or production caused bymalformation, tumors, hemorrhage,

infection or trauma.

-results in head enlargement andincreased ICP.


4/29

FUNCTIONS OF CSF

buffers the brain to protect it from normal

movements of the head

cushions the spinal and brain from jolts.

it helps maintain normal chemical balance

it assists in the maintenance of the blood-

brain barrier.

Protects brain from chemical intrusion fromthe rest of the body.


5/29

O

nce formed, (in the choroid plexus) CSF circulates throughout theventricular system, exits the foramen of Magendie and Luschka circulates

through the subarachnoid space of the spinal cord and brain, and is then

absorbed.

(Normal production of CSF in adults: 500 ml per day and in a child 25 ml per

day.)

NORMAL CSF FLOW


6/29

The term hydrocephalus is derived from the Greek, hydor (water) and kephale

(head). Hydrocephalus is an accumulation of cerebrospinal fluid (CSF) in the

ventricles, which results in dilatation of the ventricles. As fluid volume increases,

pressure increases within the intracranial vault.


7/29


8/29

TYPES:

NONCOMMUNICATING:Obstruction of

cerebrospinal flow within

the ventricular system

occurs. "obstructive"

hydrocephalus - occurs

when the flow of CSF is

blocked along one or more

of the narrow pathways

connecting the ventricles.

COMMUNICATING:Hydrocephalus occurs as

a result of impaired

absorption within the

subarachnoid space.

Interference of the

cerebrospinal fluid within

the ventricular system

does not occur. CSF is

blocked after it exits fromthe ventricles


9/29

Congenital hydrocephalus

The cranial bones fuse by the

end of the third year of life. Forhead enlargement to occur,hydrocephalus must occurbefore then. The causes areusually genetic but can also beacquired and usually occur

within the first few months oflife, which include 1)intraventricular matrixhemorrhages in prematureinfants, 2) infections, 3) type IIArnold-Chiari malformation, 4)

aqueduct atresia and stenosis,and 5) Dandy-Walkermalformation.

Acquired hydrocephalus

This condition is acquired as aconsequence of CNS-infections,meningitis, brain tumors, headtrauma, intracranial hemorrhage(subarachnoid orintraparenchymal) and is usually

extremely painful for the patient.


10/29

Arnold-Chiari malformation is a congenital anomaly of

the brain in which the cerebellar tonsils are elongatedand pushed down through the opening of the base of the

skull (see foramen magnum), blocking the flow of

cerebrospinal fluid (CSF).

Under surface of the cerebellum.

(Tonsil visible at center right.)

Sagittal section of the cerebellum, near thejunction of the vermis with the hemisphere.

(Tonsil visible at bottom center.)


11/29

Dandy-Walker syndrome (DWS), or Dandy-Walker complex, is a

congenital brain malformation involving the cerebellum and the fluid

filled spaces around it.

The Dandy-Walker complex is a genetically sporadic disorder that

occurs one in every 25,000 live births, mostly in females.

All of the black in the middle is water and the brain matter is the rim of white

along the outside of the skull.


12/29

Causes of hydrocephalusHydrocephalus develops when there is impedance to CSF flow or

absorption.

Rarely hydrocephalus will occur due to the overproduction of CSF, as inchoroid plexus papilloma.

Congenital anomalies, including aqueductal stenosis, Chiari I and IImalformation, and Dandy-Walker malformation. (Most common causes ofhydrocephalus during the neonatal and early infancy period.)

Acquired hydrocephalus problems in infancy are most commonly secondary tointraventricular hemorrhage due to prematurity (Greenberg, 2001).

Infections in utero also are a factor in some cases of neonatal hydrocephalus,and are caused by viruses or bacteria.(Guinea pigs, rabbits, and cats areknown to be vectors for viruses that can cause asymptomatic infection inpregnant women. However, the virus crosses the placenta to cause potentially

catastrophic neurologic problems in the developing fetus (Wright et al., 1997).Therefore, pregnant women should be counseled to avoid exposure to theseanimals.

Masses such as tumors, vascular malformations or cysts, and hematomasecondary to trauma.

Infectious processes such as meningitis can impede reabsorption of CSF at

the level of the arachnoid villi resulting in hydrocephalus (Greenberg, 2001).


13/29

DIAGNOSIS:

-Ultrasonography

-CT Scan

-MRI (MRI cine is a new investigation used to evaluate

hydrocephalus. Its value is not established yet.)


14/29

Medical Care:

Medical treatment is used to delay surgical intervention. It may be

tried in premature infants with post hemorrhagic hydrocephalus (inthe absence of acute hydrocephalus). Normal CSF absorption

may resume spontaneously during this interim period.

Medical treatment is not effective in long-term treatment of chronic

hydrocephalus. It may induce metabolic consequences and thus

should be used only as a temporizing measure.

Medications affect CSF dynamics by the following mechanisms:

Decreasing CSF secretion by the choroid plexus -

Acetazolamide and furosemide

Increasing CSF reabsorption - Isosorbide (effectiveness isquestionable)

Decadron may be administered to decrease edema

secondary to increased ICP.


15/29

Acetazolamide (ACZ) and furosemide (FUR) treat posthemorrhagic hydrocephalus in

neonates. Both are diuretics that also appear to decrease secretion of CSF at the level

of the choroid plexus. ACZ can be used alone or in conjunction with FUR. The

combination enhances efficacy of ACZ in decreasing CSF secretion of the choroid

plexus. If ACZ is used alone, it appears to lower risk of nephrocalcinosis significantly.

Medication as treatment for hydrocephalus is controversial. It should be used only as a

temporary measure for posthemorrhagic hydrocephalus in neonates.

Drug Category: Carbonic anhydrase inhibitors -- These agents inhibit an enzyme found

in many tissues of the body that catalyzes a reversible reaction in which carbon dioxide

becomes hydrated and carbonic acid dehydrated. These changes may result in a

decrease in CSF production by the choroid plexus.


16/29

ASSESSMENT:

1. INFANT:Increased head circumference. > 98th

percentile of age

Thin, widely separated bones of the headthat produce a cracked spot sound(Macewens sign) on percussion.

Anterior fontanel tense, bulging, and nonpulsating.

Dilated scalp veinsFrontal bossing

Sun setting eyes

2. CHILD:

Behavior changes such as irritability andlethargy.

Headache on awakening

Nausea and vomiting

Ataxia

Nystagmus

Papilledema: if the raised ICP is not treated,this can lead to optic atrophy and visionloss.

Failure of upward gaze: This is due topressure on the tectal plate through thesuprapineal recess.

Macewen sign: A "cracked pot" soundis noted on percussion of the head.

Unsteady gait: This is related tospasticity in the lower extremities.

Large head: Sutures are closed, butchronic increased ICP will lead to

progressive abnormal head growth. Unilateral or bilateral sixth nerve palsy

is secondary to increased ICP.

LATE SIGNS: a high and shrill cry and seizure

activities


17/29

NURSING MEDICAL

INTERVENTIONS:

Monitor vital signs

Assess for any progression of headcircumference. Monitor any change or increase inthe head circumference, change in feeding

patterns etc (as written on the previous slide)Administer medications as prescribed

Utilize aseptic and or clean technique in anyprocedure to prevent infection

Assess nutritional status of patientProvide comfort and safety

Provide emotional support to patient and family


18/29

Drug Name

Acetazolamide (Diamox) -- Noncompetitive reversible inhibitor of enzyme

carbonic anhydrase, which catalyzes the reaction between water and carbon

dioxide, resulting in protons and carbonate. This contributes to decreasing CSF

secretion by choroid plexus.

Pediatric Dose 25 mg/kg/d PO tid; not to exceed 100 mg/kg/d

Contraindicatio

ns

Documented hypersensitivity; hepatic insufficiency, hyponatremia, hypokalemia,

hyperchloremic acidosis, severe renal insufficiency, nephrocalcinosis, adrenal

gland failure

Interactions

Alkalizes urine and may decrease excretion of amphetamines, procainamide,

quinidine, flecainide, anticholinergics, and mecamylamine; may increaseexcretion and lower plasma levels of salicylate, phenobarbital, and lithium; can

increase cyclosporine levels and decrease primidone levels; concurrent

salicylates may increase accumulation and toxicity, including CNS depression

and metabolic acidosis

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions

Can cause hyperglycemia in diabetics; concurrent digoxin can increase

susceptibility to ACZ-induced hypokalemia; in patients taking other diuretics,

ACZ can aggravate hypokalemia; can aggravate preexisting acidosis, which can

be prevented by initiating prophylactic electrolyte replacement; this may consist

of sodium citrate starting at 8 mEq/kg/d titrated, keeping serum bicarbonate

levels >18 mEq/L and sodium and potassium within reference ranges

Obtain baseline CBC prior to initiating therapy; recheck regularly during therapy


19/29

Drug Category: Loop diuretics -- These agents increase excretion of water by

interfering with the chloride-binding cotransport system, which results from inhibition of

reabsorption of sodium and chloride in the ascending loop of Henle and distal renal

tubule.

Drug Name

Furosemide (Lasix) -- Mechanisms proposed for lowering ICP

include lowering cerebral sodium uptake, affecting water transport

into astroglial cells by inhibiting cellular membrane cation-chloride

pump, and decreasing CSF production by inhibiting carbonic

anhydrase. Used as adjunctive therapy with ACZ in temporary

treatment of posthemorrhagic hydrocephalus in neonates.

Pediatric Dose 1 mg/kg/d IV

Contraindications

Documented hypersensitivity to drug or sulfonylureas, hepatic

coma, anuria, severe electrolyte depletion, concurrent ethacrynic

acid (may cause ototoxicity), or lithium (may cause lithium toxicity)

Interactions

May increase ototoxic potential of aminoglycoside antibiotics; may

increase salicylate toxicity if given with salicylate; may decreasearterial response to norepinephrine

Pregnancy C - Safety for use during pregnancy has not been established.

Precautions

Excessive use can cause dehydration and circulatory collapse; can

cause electrolyte imbalance as hypokalemia, hyponatremia,

hypochloremic alkalosis, hypomagnesemia, and hypocalcemia;

therefore, monitor serum electrolytes; may increase blood glucosein patients with diabetes; may cause photosensitivity


20/29

Drug Category: Corticosteroids-are a class ofsteroid hormones that are produced in the adrenal cortex.

Corticosteroids are involved in a wide range ofphysiologic systems such as stress response, immune

response and regulation ofinflammation, carbohydrate metabolism, protein catabolism, blood electrolyte

levels, and behavior.

Drug Name

Decadron is an steroid and it comes in Intravenous as well as oral tablets. Intravenous

form is used for immediate action and result and tablets are used to maintain the effect

of Decadron

Pediatric DoseThe range of initial doses is 0.02 to 0.3 mg/kg/day in three or four divided doses (0.6to 9 mg/m2bsa/day).

Contraindications

Systemic fungal infections (see WARNINGS,Fungal infections).DECADRON tablets are contraindicated in patients who are hypersensitive to any components of thisproduct.

Interactions

This drug should not be used with the following medications because very serious interactions may

occur: live vaccines, mifepristone. Before using this medication, tell your doctor or pharmacist of allprescription and nonprescription/herbal products you may use, especially of: aminoglutethimide, largedoses of aspirin and aspirin-like drugs

Precautions

Do not have immunizations, vaccinations, or skin tests unless specifically directed by your doctor. Livevaccines may cause serious problems (e.g., infection) if given while you are using this medication.Avoid contact with people who have recently received oral polio vaccine or flu vaccine inhaled throughthe nose.This medication may mask signs of infection or put you at greater risk of developing very seriousinfections. Report to your doctor any injuries or signs of infection (e.g., persistent sore

throat/cough/fever, pain during urination, muscle aches) that occur while using this medication orwithin 12 months after stopping it.Before using this medicine, consult your doctor or pharmacist if you have: current fungal infections.Caution is advised when using this drug for a long time in children. This medication may temporarilyslow down a child's rate of growth, but it will probably not affect final adult height. Monitor your child'sheight periodically.A preservative (benzyl alcohol) that may be found in some dexamethasone products, which are notpreservative-free, can infrequently cause serious (sometimes fatal) problems if given in large amounts(more than 100 milligrams per kilogram daily) to an infant during the first months of life. The risk is also

greater with low-birth-weight infants. Symptoms include sudden gasping, low blood pressure, or a veryslow heartbeat. If you notice any of these symptoms in your newborn, report them to the doctorimmediatel . If ossible use the reservative-free form of this dru when treatin newborns.


21/29

SURGICAL INTERVENTIONS:

1.The goal of surgical treatment is to preventfurther CSF accumulation by bypasing theblockage and draining the fluid from the ventriclesto a location to where it maybe absorbed.

2. In ventriculoperitoneal shunt, the CSF drainsinto the peritoneal cavity from the lateral ventricle.

3. In an atrioventricular shunt, CSF drains into theright atrium of the heart from the lateral ventricle,bypassing the obstruction (used in older childrenand in children with pathological conditions of theabdomen.)


22/29


23/29

NURSING INTERVENTIONS

POST OPERATIVELY:

Monitor vital signs and neurological signs.

Position the client on the un-operated side to prevent pressureon the shunt bulb.

Keep the child flat as prescribed to avoid rapid reduction ofintracranial fluid.

Observe for increased ICP; if increased ICP occurs, elevate thehead of the bed to 15 to 30 degrees to enhance gravity flowthrough the shunt.

Monitor for signs of infection and assess dressing for drainage.

Measure head circumference.

Monitor intake and output.

Provide comfort measures; administer medications as

prescribed, which may include diuretics, antibiotics, oranticonvulsants.

Instruct parents on how to recognize shunt infection ormalfunction.

In a toddler, headache and a lack of appetite are the earliestcommon signs of shunt malfunction.


24/29

COMPLICATIONS:Related to progression of hydrocephalus

Visual changesOcclusion of posterior cerebral arteries secondary to downward transtentorial herniation

Chronic papilledema injuring the optic discDilatation of the third ventricle with compression of optic chiasm

Cognitive dysfunction

Incontinence

Gait changes

Related to medical treatmentElectrolyte imbalance

Metabolic acidosis

Related to surgical treatmentSigns and symptoms of increased ICP can be a consequence of undershunting or shunt obstruction ordisconnection.

Subdural hematoma or hygroma is secondary to overshunting. Headache and focal neurological signsare common.

Treat seizures with antiepileptic drugs.

Shunt infection occasionally can be asymptomatic. In neonates it manifests as alteration of feeding,

irritability, vomiting, fever, lethargy, somnolence, and a bulging fontanelle. Older children and adultspresent with headache, fever, vomiting, and meningismus. With VP shunts, abdominal pain may occur.

Shunts can act as a conduit for extraneural metastases of certain tumors (eg, medulloblastoma).

Hardware erosion through the skin occurs in premature infants with enlarged heads and thin skin wholie on 1 side of the head.

VP shunt complications include peritonitis, inguinal hernia, perforation of abdominal organs, intestinalobstruction, volvulus, and CSF ascites.

VA shunt complications include septicemia, shunt embolus, endocarditis, and pulmonary hypertension.

Lumboperitoneal shunt complications include radiculopathy and arachnoiditis.


25/29

Symptoms of Shunt

Malfunction/Hydrocephalus

A shunt infection can also cause the shunt not towork properly and cause CSF to backup, leadingto enlarged ventricles. Signs and symptoms ofshunt infection also relate to signs of shunt

malfunction. In addition, other signs andsymptoms related to shunt infection include:

Fever.

Redness, tenderness, skin breakdown, or fluidcollection noted at the shunt on the scalp or

anywhere along the shunt tract.

Drainage at the incisional areas related to theshunt.

Abdominal pain, tenderness, or refusing to eat or

drink


26/29

INFANTS

Enlargement of thebabys head

Fontanel is full and

tense when the infant

is upright and quiet

Vomitting, Irritability,

Sleepiness, downward

deviation of the eyes Seizures

TODDLERS

Head enlargement

Vomitting

Headache

A loss of previousabilities (sensory of

motor function)

Seizures

Lack of apetite


27/29

OLDER CHILDREN

Vomiting

Vision problems

Irritability and or tirednessLoss of coordination and balance

Difficulty in waking up or staying

awakeSeizures

Decline in school performance


28/29

For the most part, shunts function well. However,there are complications that can occur. Ablockage or obstruction of the shunt is the most

common complication of the system. Obstructionmay occur at any point along the path of theshunt. The opening at the ventricular end maybecome plugged with brain, choroid plexustissue, or blood. The peritoneal end may alsobecome blocked by scar tissue. An obstructedshunt causes an increased volume of CSF in theventricular system of the brain. This can lead tothe same symptoms as those listed below forhydrocephalus. The shunt can be repaired(shunt revision) in surgery lasting about 1 2hours.


29/29

Reference

Medical Surgical

textbooks: Bruners

and Sudarths,Saunders

Internet

Nurse Avenue

Medscape

MASSIVE INTRACRANIAL FLUID COLLECTION

Documents

Transcript of MASSIVE INTRACRANIAL FLUID COLLECTION