Neurosurgery

1. EMERGENCIES IN NEUROSURGERY
MANAGEMENT OF
ACUTE
HYDROCEPHALUS
29-9-2012
Dewan Auditorium, HTAA

2. Medical
Management of
Hydrocephalus
• Diuretics (frusemide and
acetazolamide) and steroids are
known to decrease CSF production.
• Maintaining PaCO2

3. Surgical
Management of
Hydrocephalus
• Surgical drainage of CSF appears to date from the time of
Hippocrates, but it was not until the 18th century that ventricular
drainage was seriously attempted.
• By the 19th century, it had become clear that prevention of
infection would require internal CSF drainage.
• Virtually every cavity has been tried, including the subdural
space, the subarachnoid space, the subcutaneous tissues of
the scalp, the paranasal sinuses, the thoracic duct, the
pleura, the peritoneum, the gall bladder, the ureters, and the
bloodstream.

4. Surgical
Management of
Hydrocephalus
• The atrium was initially the preferred site for placement of the
distal catheter in children, but atrial shunts have a unique set
of complications including endocarditis and
glomerulonephritis.
• They also migrate from the atrium with linear growth of the
child, needing surgical revision of the distal catheter.
• The peritoneum is now the ―favoured‖ site for the distal
catheter unless there are problems with absorption or
abdominal sepsis.
• Lumbar peritoneal shunts are rarely used for the treatment of
hydrocephalus in children and have been associated with the
development of scoliosis and cerebellar tonsillar herniation.

5. Surgical
Management of
Hydrocephalus
• Although results for treating hydrocephalus
were far superior, it soon became apparent
that shunts had their limitations.
• Three ways in which shunts can
malfunction:
– (a) they can become infected;
– (b) they can fail mechanically;
– (c) they can overdrain or underdrain (termed a
―functional‖ failure)

6. Surgical
Management of
Hydrocephalus
• Open third ventriculostomy (TV)—literally making a hole to
connect the third ventricle with the subarachnoid space—was
first reported in the 1920s by Dandy, but it had significant
mortality.
• It was not until the last two decades that endoscopic TV has
grown in popularity as an alternative to shunt placement for
patients with triventricular (obstructive) hydrocephalus

7. • Endoscopic TV entails entering the lateral
ventricle, passage through the Foramen of
Monro, identification of the mamillary bodies, and then
perforation of the floor of the third ventricle just anterior
to the bifurcation of the basilar artery

8. Creating alternative CSF pathways (third ventriculostomy),
reducing the CSF production (choroid plexus coagulation), or
restoring the physiological ones (aqueductoplasty, septostomy, foraminal plasty
of foramen of Monro, and foraminal plasty of foramens of Magendie and/or
Luschka)
Neuroendoscopy provides a magnified view of the ventricular system
viewed from inside and allows a better resolution of the surgical field.
It avoids the implant of foreign bodies and reduces the need for
re-intervention commonly observed in shunted patients, with
the potential to avoid shunt dependency

9. Hemorrhage
(the most severe being due to basilar rupture)
Injury of neural structures
. In the immediate
postoperative period
Hematomas, infections, an
d
cerebrospinal fluid leaks

10. Utility of point of obstruction model

11. Basal Meningitis and Hydrocephalus
CT and MRI
2 samples of lumbar CSF analysis from 2 different lumbar punctures.
The CSF was sent for routine cytological and biochemical evaluation,
bacterial and fungal cultures, antituberculosis and anticysticercosis
antibodies, and India ink preparation for cryptococcosis.
Gram stains, cultures, serology and cytology
were negative
Neuroendoscopic Exploration of the
Subarachnoid Basal Cisterns
septum pellucidum fenestration,
ETV, aqueductoplasty, Liliequist
fenestration, and basal cisternal dissection

12. Basal Meningitis and Hydrocephalus
Transventricular Neuroendoscopic Exploration and Biopsy of the
Basal Cisterns

13. Hydrocephalus in TB Meningitis
MEDICAL MANAGEMENT
The appropriateness of this therapeutic approach depends on three key factors:
1) Demonstration of communication between the ventricles and the subarachnoid space;
2) Prevention of ongoing increased ICP during the treatment phase;
3) Adherence to a strict protocol for treatment and monitoring of ICP.
Treatment
with furosemide and acetazolamide,
with weekly lumbar puncture pressure
measurements,
Repeat the cranial CT
after three weeks of treatment, or earlier if
there is a clinical indication.
Has been reported to be successful
in approximately 75% to 80% of patients

14. Hydrocephalus in TB Meningitis
SURGICAL MANAGEMENT
Repeat the cranial CT
after three weeks of treatment, or earlier if
there is a clinical indication.
If there is progression
of the hydrocephalus on head CT,
or if ICP control is still not achieved
by three weeks
depressed level of consciousness,
temporary external
ventricular drainage
Endoscopy TV
Receives a VPS.
who do not respond to medical therapy or who have
NCHC.

15. Hydrocephalus in TB Meningitis
SURGICAL MANAGEMENT
Endoscopy TV
first described in 2003 as an alternative to VPS
insertion in patients with NCHC
The clinical outcome of the hydrocephalus
in a nonselective approach to ETV was reported
as “satisfactory” in 50% and “acceptable” in 18%
If the ETV cannot be completed technically,
Perform lumbar punctures
for a few days after the ETV
VPS.

16. Shunt Malfunction
presence of an obstructive
hydrocephalus at the time of
Frequently located at the level of the aqueduct,
shunt malfunction with a radiological appearance of triventricular
hydrocephalus.
Preoperative evaluation
by magnetic resonance imaging
(MRI) is mandatory to assess anatomical
suitability and the patency of the aqueduct
and fourth ventricle outlets.
Absolute anatomical considerations are that Lateral ventricle, foramen of
Monro, and the third ventricle should be large enough to admit the endoscope;
there should be no major anatomical abnormality of the third ventricle;
there should be some space between the dorsum sellae and the basilar
Endoscopy TV
Ideally there should not be any
marked degree of arachnoid membranes in
the prepontine cistern.

17. Shunt Malfunction
Posthemorrhagic hydrocephalus.
(A) CT scan at first
presentation, showing tetraventricular
hydrocephalus. The patient was
managed with insertion of a VP shunt.
(B) CT scan at shunt
malfunction.
(C) Mid-sagittal T2 MRI showing
stenosis of the aqueduct and bulging of
the floor of the third ventricle in the
interpeduncular cistern.
(D) Post-ETV mid-sagittal T2 MRI.
CT, computed tomography;
Endoscopy TV

18. Results of ETV in Shunt Infection
shunt infection should not
be considered a contraindication to ETV,
even though the success rate may be lower.
Third ventriculostomy
offers a welcome alternative to the
management of this group of patients

19. TREATMENT OF HEMATOCEPHALUS
Massive intraventricular hemorrhage is a
life-threatening condition that requires aggressive
management to decrease intracranial
hypertension.
The control of intracranial
pressure by external ventricular drainage is
a rescue surgical action
tetraventricular
blood flooding should be often
managed with bilateral ventricular
catheter

20. TREATMENT OF HEMATOCEPHALUS
In these cases to treat patients surgically
for hematoma removal if deemed, and
to place an external ventricular
drainage immediately.
serial computed tomographic
(CT) scans;
if a good clinical response
is obtained in the early days after
surgery
Reconsider endoscopic removal
of clots in cases with massive
ventricular
hemorrhage and tetraventricular
extension
Oral anticoagulant
therapy should be considered a contraindication
for early endoscopic treatment

21. TREATMENT OF HEMATOCEPHALUS
If ventricular clots are secondary to aneurysm
rupture or arteriovenous malformations
Fisher 4 subarachnoid
hemorrhage with massive tetraventricular
clots
Perform early surgery or coiling to
secure the aneurysm or malformation
in patients who are
intubated and have a Glasgow Coma Scale
score 6 (motor response 4–5)
decrease intracranial hypertension by
endoscopically cleansing clots
Early endoscopic
aspiration in patients

22. NORMAL PRESSURE
HYDROCEPHALUS
NPH who improve clearly after one
or several CSF lumbar punctures.
proceed with shunting
More marked symptoms and a longer history earlier
Extensive counselling with the patients’
relatives should be performed to
weigh the expected benefits from
shunting and the possibilities of long-term
shunt dysfunction
Patients at an early clinical stage
with mild gait disturbance
may be monitored initially,
repeated CSF removal via lumbar puncture
disease should progress
proceed with shunting

23. Acute Obstructive Hydrocephalus Caused
by Cerebellar Infarction
Immediate intubation to control ventilation
and prevent buildup of Paco2.
Intravenous administration of
dexamethasone and mannitol.
prompt improvement in the state of consciousness
is not detected
Ventriculostomy and external ventricular
drainage
Prompt suboccipital craniectomy with resection of
necrotic cerebellar tissue if there is no amelioration in the
level of consciousness within a few hours after
ventricular decompression.
If external ventricular drainage is effective
and consciousness is restored,
Repeat CT scan in 48-72 hours
will perhaps confirm a decrease in
mass effect and stabilization or
reduction of ventriculomegaly
Toward the end of the first week the need
for conversion to a shunt (if clamping or
elevation of the emptying pressure of
the ventriculostomy tube is followed
by clinical regression. ) can be
determined.

24. Correction of Congenital Hydrocephalus
in Utero
In utero decompression
of obstructive hydrocephalus improves
overall survival
Improves gross ventriculomegaly,

25. Thank You