Seminar Hydrocephalus Surgery Yr 4 Rotation 3
Transcript of Seminar Hydrocephalus Surgery Yr 4 Rotation 3
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Management of HydrocephNeurosurgery Rotation 3
UiTM MBBS Year 4 (2013/2014)13thDecember 2013
1- MUHAMMAD KYIDIR BIN MOHD IDROS
2- NAZURAH NADIA BT. AZIMUDDIN
3- MUHAMAD ASRI B. ABD RAHMAN
4- MOHD RIDZUAN BIN HAMID
5- MOHAMMAD FIKRI B. ROSLI
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ANATOMY OF VENTRICULARSYSTEM2 Lateral Ventricles
Largest cavity
Occupies large area of cerebral
hemisphere Opens through interventricular
foramen into the 3rdventricle
3rdVentricle
Slit-like cavity between the two
thalami (each side)
Continues posteroinferiorly with
Aqueduct of Sylvius
4thVentricle
Pyramidal in shape
Posterior to the pons and medulla
Extends inferoposteriorly
Inferiorlynarrow central canal in
spinal cord
FlowsForamen of Luschka and
Foramen of Magendie
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CSF PRODUCTIONAND FLOW
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Physiology of CSF Formation
Secreted by choroid plexus of:
Inferior horn of each lateral ventricle
Posterior portion of 3rdventricle
Roof of 4thventricle
Humans total volume of CSF is about 120-150 mL and the rate of CSF production
about 0.5 mL/min (400-500 ml/day) and the CSF turnover time of about 5 hours.
It has been estimated that 50-70% of the CSF is formed in the choroid plexuses an
the remainder is formed around blood vessels and along ventricular walls.
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CSF FLOW2 Lateral ventricles
2 Foramen of monro
3rdventricle
Aqueduct of Sylvius
4thventricle
2 lateral foramina of Luschka
1 midline foramen of Magendie
Subarachnoid space
With the aids of
ciliatedependymal cell,
arterial
pulsation of
choroid plexus
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Subarachnoid space
2 ways:
Superiorly-inferior surface of cerebrum andlater to lateral aspect of cerebral hemisphere
Inferiorly-spinal cord and cauda equinabefore rises superiorly
Arachnoid granulation
(villi)
Venous system(Superior sagittal sinus)
CSF ABSORPTIONWith th
cerebra
puls
Pas
dep
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CSF PRESSURE The pressure is kept remarkably constant
In lateral recumbent positionPressure measured by spinal tap/lumbar puncture is
~60-150 mm water
Pressure may be raised by straining, coughing andcompressing internal jugular vein (raised ICP;one-pressureway causing no csf reabsorption, hence increases csf
pressure) Production of CSF is not pressure regulated
Continues to be produced even if reabsorption mechanism isobstructed
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Normal constituents of CSF
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PHYSICAL CHARACTERISTICS OCSF
CharacteristicsAppearance Clear and colorless
Total Volume 150 ml
Rate of production ~0.5 ml/minute (~500ml/day)
Composition
Protein
Glucose
Chloride
0.15-0.45 g/l
0.5-0.85 g/l (50% blood glucose)
7.2-7.5 g/l
Number of cells 0-3 lymphocytes
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Bacterial Meningitis
Appearance - Cloudy & Turbid
White Cells - Raised neutrophils
Red Cells - Absent
Protein - High or Very HighGlucose - Very Low
Viral Meningitis
Appearance - Normal
White Cells - Raised lymphocytes
Red Cells - Absent
Protein - Normal or HighGlucose - Normal or Low
Tuberculous Meningitis
Appearance - Normal or Slightly CloudyWhite Cells - Raised lymphocytes
Red Cells - Absent
Protein - High or Very High
Glucose - Very Low
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Guillan-Barr Syndrome
Appearance - Normal
White Cells - Normal
Red Cells - Absent
Protein - HighGlucose - Normal or Low
Multiple Sclerosis
Appearance - NormalWhite Cells - Raised lymphocytes
Red Cells - Absent
Protein - High
Glucose - Normal
Subarachnoid Hemorrhage
Appearance - Usually blood stained
White Cells - Normal
Red CellsPresent (Very High)
Protein - Normal or HighGlucose - Normal or Low
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FUNCTIONS OF CSF
1. Cushions - protects CNS from mechanical trauma
2. Bouyancy
3. Reservoir and assists in the regulation of the contents of the skull - inbrain volume/blood volume will increase CSF volume
4. CNS nourishment
5. Removal of metabolites from CNS
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HYDROCEPHALUS
NAZURAH NADIA
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Definition
increased volume of cerebrospinal fluid (CSFwithin the skull, most frequently in theventricles.
Textbook of Clinical Neurology,
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The accumulation of excessive CSF within thventricular system may d/t:
1. Impaired flow (obstructive/non-communicating)
2. Impaired resorption (communicating)
3. Overproduction (communicating)
increase ICP
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Classification
1. Non-communicating Hydrocephalus(Obstructive)
2. Communicating Hydrocephalus (Non-
obstructive)
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1. Non Communicating Hydrocephalus Obstructive hydrocephalus
CSF flow obstruction in the ventricular system
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Ventricular System
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Aqueductal stenosis
Abscess
Chiari malformation
Dandy-Walker malformation
Hematoma
Infectious
Klippel-Feil syndrome
Mass lesions
Tumors & neurocutaneous disorders
Vein of Galen malformation
Walker-Warburg syndrome
X-linkedClinical pediatric neurology : A sign & symptoms approach, Gerald M.
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2. Communicating Hydrocephalus Non-obstructive hydrocephalus
Impaired CSF resorption: Sub ArachnoidHemorrhage(SAH)
Functional impairment of the arachnoidgranulations (congenital)
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Causes
Infants & children
Congenital
Acquired
Adults
Acquired
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Examples-CongenitalDANDY WALKER MALFORMATION
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Clinical features
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Effects (clinical features)
The clinical features depend on:
Age
Cause
Location of obstruction
Duration
Rapidity of onset
Setti S.Rengachary, Richard G. Ellenbogen. Principles Of
Neurosurgery.Second Edition.2005.Elsevier Mosby
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Infants
Irritability
Vomiting
Drowsiness
Macrocephaly
Distended scalp veins
Frontal bossingpositive Macewenssignpoor head controllateral rectus palsysetting-sun sign
Setti S.Rengachary, Richard G. Ellenbogen. Principles Of
Neurosurgery.Second Edition.2005.Elsevier Mosby
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Acute (high-pressure) hydrocephalu
oHigh ICP:
Headache
Nausea
Vomiting
Papilloedema
oAbducens palsy & truncal ataxia, may, incorrectly, suggest a fossa lesion (false localizing sign)
oEpisodic visual obscurations graying- dangerous pressure w
Setti S.Rengachary, Richard G. Ellenbogen. Principles Of
Neurosurgery.Second Edition.2005.Elsevier Mosby
Chronic or normal pressure hyrocep
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Chronic or normal pressure hyrocep(NPH)Clinical triad of NPH:
Gait disturbance- magnetic, apraxic
Urinary incontinence- uninhibited neurogenic bladder
Dementia
Setti S.Rengachary, Richard G. Ellenbogen.
Principles Of Neurosurgery.Second
Edition.2005.Elsevier Mosby
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Papilloedema 6thnerve palsy
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Imaging studies forhydrocephalus
-MOHD RIDZUAN BIN HAMID-
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Imaging modalities
Skull ultrasound
Skull radiograph (x-ray)
CT Scan
MRI
Skull ultrasound
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Skull ultrasound
Uses high frequency sound wave
Method of choice to diagnose intra-
uterine cases
First investigatory method forinfantile cases(6months-2y/o)
- open anterior fontanelle, simpleprocedure, non-invasive
Internal cranial structure (ventricles,parenchyma,vessels) are visualizedin coronal and saggital planes
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Ventricular
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Ventricular-hemisphericratio
Level of Foramen ofMonroe in coronal section
Distance of the lateral wallof lateral ventricle from
midline to the hemisphericwidth
If > 0.35, suggestive ofhydrocephalus
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Skull radiograph
Simple, inexpensive and non invasive imaging method with
diagnostic value Used in older children
anterior fontanelle closed
ultrasound cannot penetrate bony structure
Can detect several diagnostic signs
Enlarged craniumWide spread / split sutures
Disproportionate craniofacial ratio
J-shaped sella
silver beaten appearance of calvarium
Enlarged cranium
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Enlarged cranium
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Compressed cerebral sulci
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Compressed cerebral sulci
Enlarged fron
Enlarged 3rdventricle
Enlarged temporal horn
MRI
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MRI
Can project the brain in axial,coronal,and saggital pro
provide better anatomical detail of lesions causinghydrocephalus and is particularly useful in the diagno
aqueduct stenosis
Can detect transependymal resorption and low grade
more clearly than CT-scan Can detertmine CSF flow across aqueduct
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NormalDilatation of Ventricles
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Dandy Walker
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Dandy WalkerSyndrome
Everted hypoplasticvermis (long arrow)
Large posterior fossacyst (short arrow)
Hypoplasia of thebrainstem andcerebellum (b)
MRI/CT Criteria
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MRI/CT Criteria
Acute Hydrocephalus
Size of both temporal horns (>2mm)/clearly visible (normally-barely visible)
Evans ratio >30%. (Evans ratio-ratio ofthe largest width of the frontal hornsto maximal biparietal diameter.
Ballooning of frontal horns of lateralventricles and third ventricle-mightindicate aqueductal obstruction.
Upward bowing of corpus callosum onsaggital MRI.
Chronic Hydroceph
Temporal horns may bprominent compared thydrocephalus.
Third ventricle may hesella turcica
Sella turcica may be er Macrocrania (ie, occipitofronta
>98thpercentile) may be present.
Corpus callosum maybatrophied
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Management ofHydrocephalusMohammad Fikri Bin Rosli
Management of Hydrocephalus
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Management of Hydrocephalus
Acute hydrocephalus: emergency as condition mayprogress over minutes or hours to coma and death.
Management
Medical Surgical
Medical management
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Medical management To delay surgical intervention
Not effective in long term treatment of chronic hydrocephalus
Acetazolamidecarbonicanhydrase inhibitors
Furosemideloop diuretics
Reduce CSFproduction
IsosorbideIncrease CSFreabsorption
S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2
Surgical management
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g g
1) External ventricular drainage (EVD)
Temporary measure to relieve hydrocephalus
Catheter are inserted to the right of midline, anterior tocoronal sutures to enable the tip of catheter rest adjacent tthe foramen of monro in lateral ventricle
Catheter connected to a drain set which the CSF will drainswhen the ventricular pressure exceeded 20mmHg
Bailey & Loves Short Practice of Surgery 26t
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Ventriculoatrial shuntVentriculoperitoneal
shunt
Ventriculopleural
shunt
Consist of 3 components:
Proximal ventricular catheter
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Proximal ventricular catheter
One way valve: permits CSF flows out of ventricular
Opening pressure of the valve can be high, medium or low
High pressure may cause inadequate drainage of CSF
Low pressure may cause over-drainage of CSF
Distal catheter: allow the fluid to flows into the reservoir, allow CSF to beaspirated
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Shunt blockagedue to cellular and proteinaceous debris, choroid plexus adhesion
Low pressure syndromedue to over-drainage of CSF which consist of headache wstanding, neck pain, and nausea
Subdural hematoma or subdural hygromadue to collapsed ventricles causing accufluid in subdural space
S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2
3) Endoscopic third ventriculostomy
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Useful in obstructive hydrocephalus due to aqueduct stenosis
Neuroendoscopeinserted into frontal horn of lateral ventricle and theninto third ventricle via foramen of monro
Complication
Reblockage
Damage to basillar artery
Damage to the fornix
Bailey & Loves Short Practice of Surgery 26t
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Other type of
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Other type ofhydrocephalus
Hydrocephalus ex vacuo
Normal pressure hydrocephalus
TBM and hydrocephalus
Hydrocephalus Ex Vacuo
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Occur in the presence of brain damage due to stroke, injury or actualshrinkage of brain substance
Brain are atrophied and wasted
Features are:
Increased production of CSF
Cerebral atrophy
Dilatation of the ventricles
ICP usually is normal. HOWEVER
Causes: Alzheimer disease, Multiple sclerosis, Multiple strokes, Huntingtdisease, Leukodystrophies.
http://www.medicinenet.com/hydrocephalus/page
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Mild to moderate cortical atrophy.
Large ventricles, particularly the
third ventricle and inferior horns of
the lateral ventricles.
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Triad of clinical features: Gait disturbance, urinary incontinence andcognitive decline (dementia)
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cognitive decline (dementia)
Opening pressure on LPtypically normal
Lumbar infusion testing can also be done to measure CSF pressure.
Imagingusually reveals ventriculomegaly Treatment
Ventriculoperitoneal shunt
http://emedicine.medscape.com/article/1150924-
Bailey & Loves Short Practice of Surgery 26thEditio
http://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overview -
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Hydrocephalus is common sequelae of TBM
CT scan intense meningeal enhancement
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CT scanintense meningeal enhancement
Management:
Medical therapy: steroids eg: prednisolone and anti-tuberculosis drug. Surgery: Ventriculoperitoneal shunt
Rich Foci
http://emedicine.medscape.com/article/1166190-
References
http://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overview -
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Bailey & Loves Short Practice of Surgery 26thEdition
S.Rengachary, G.Ellenbogen, Principle of Neurosurgery 2ndEdition
http://emedicine.medscape.com/article/1166190-overview
http://emedicine.medscape.com/article/1150924-overview
http://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1150924-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overviewhttp://emedicine.medscape.com/article/1166190-overview -
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