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Hydrocephalus


Medical editor Ane Konglund MD
Physician in Specialization
Oslo University Hospital

General

Hydrocephalus is a condition with an increased volume of cerebrospinal fluid (CSF) and distention of the brain's natural cavity, the ventricle system. Such an accumulation of CSF is normally due to an obstruction of the natural drainage system.

The consequence of hydrocephalus is an increased intracranial pressure (ICP).

Patients with a suspected elevated ICP and children with abnormal circumference of the head must be evaluated for treatment. Hydrocephalus is an important neurosurgical condition which, if left untreated, leads to considerable morbidity and mortality.

In many cases, the problem is not solved by treating the basic condition and the patient must have decompression of the CSF.

Treatment alternatives for hydrocephalus:

  • Surgical removal of tumor
  • Ventriculocisternostomy
  • Shunt

Ventriculocisternostomy

Non-communicative hydrocephalus with intact resorption apparatus can, for example, be due to:

  • Expansive processes in the cerebrofluid system, e.g. intraventricular tumors
  • Expansive processes outside the cerebrofluid system, e.g. paraventricular tumors around the 3rd. ventricle or in the posterior cranial fossa 

A ventriculocisternostomy should bypass the blockage (the tumor) and lead the CSF to the resorption areas on the surface of the brain.

Using the endoscopic technique, a hole or stoma can be made in the floor of the 3rd. brain ventricle (endoscopic third ventriculostomy). CSF will then flow to the basal cisterns and out to the surface of the brain and its resorption apparatus. In this way, blockages in the aqueduct can be circumvented and shunt treatment can be avoided.

About 70% of patients with non-communicative hydrocephalus will respond positvely to such a procedure.

Shunt

Communicative hydrocephalus with failing resorbtion apparatus can, among other things, be due to:

  • Increased venous pressure due to tumors that invade venous sinuses, e.g. meningiomas

With the aid of a shunt, the CSF is bypassed out of the cranium to an alternative resorption apparatus.

A shunt is a silicon tube system with a valve that leads CSF to the peritoneum (ventriculoperitoneal shunt) or to the blood stream (ventriculoatrial shunt).

Indications

  • Drainage obstruction by a tumor in the natural drainage system (non-communicating hydrocephalus)
  • Venous obstruction by a tumor (communicative hydrocephalus)

Goal

  • Achieve normalization of the intracranial pressure and the circulation of CSF

Equipment

Third ventriculocisternostomy 

  • Ventriculostomy tray 
  • Endoscopy tray
  • High speed drill
  • Monitor for image transfer

Implantation of ventriculoperitoneal shunt system  

  • Shunt tray
  • High speed drill
  • Shunt system (various types)   

Preparations

Third ventriculocisternostomy  

  • General anesthesia.
  • Place the patient in the supine position.
  • Fix the head.

Implantation of ventriculoperitoneal shunt system

  • General anesthesia.
  • Place the patient in the supine position with pillow support under head/shoulders.
  • If not contraindicated, the shunt system should be placed on the right side of the patient in order to avoid dominant hemisphere.

Implementation

Third ventriculocisternostomy 

  • Give infection prophylaxis.
  • Make a small skin incision frontally on the right side.
  • Drill a small hole and open the dura.
  • Carefully guide the endoscope until it is in the ventricle system.
  • Visualize the foramen of Monroi.
  • Move the scope caudally until the bottom of the 3rd ventricle can be seen.
  • Make a hole on the floor of the ventricle by careful manipulation. Expand this until a good flow is seen. 
  • Close the skin incision in two layers.

Implantation of ventriculoperitoneal shunt system

  • Give infection prophylaxis.
  • Make a curved skin incision frontally on the right side. 
  • Make a small drill hole and open the dura.
  • Insert a ventricle catheter for approximately 5.5 cm, or until it is in the ventricle system.
  • Take samples of spinal fluid for clinical-chemical examination and bacteriological inoculation.
  • Make a small skin incision in the midline of the abdomen (about two fingers wide) under the breast bone, and open in layers into the abdominal cavity.
  • Tunnel the abdominal catheter and shunt valve between the two incisions. It may be necessary to make an auxiliary incision behind the ear.
  • Connect the ventricle catheter to the efferent system and place the abdominal catheter in the free abdominal cavity.
  • Close all three skin incisions in layers.

Follow-up

Third ventriculocisternostomy

  • Thrombosis prophylaxis is given according to the department's guidelines until mobilization.
  • Blood tests are taken including electrolytes the first post-operative day.
  • The patient may be gradually mobilized over 1–2 days.
  • Sutures are removed after approximately 12 days. It is essential to avoid leakage.
  • MRI control should only be used in the event of the absence of clinical improvement and flow should then be seen in the stomy. 
  • The patient is normally discharged to a local hospital 1–2 days after the operation, depending on the clinical course.

Implantation of ventriculoperitoneal shunt system

  • Thrombosis prophylaxis is given routinely until full mobilization.
  • The patient must have flat or partly flat bed rest for the first 1–2 days and then gradual mobilization.
  • Sutures are removed after 10–12 days. It is essential to exclude wound infection.
  • CT control is taken at outpatient follow-up after 2 months.
  • The patient is normally discharged to a local hospital 2–3 days after the operation, depending on the clinical course.

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