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Epidural hematoma after ventriculoperitoneal shunt surgery: Report of 2 cases
Thursday, 10 July 1997
IP·6-733I
The sequential changes of intraventricular l11In·DTPA for quantitative evaluation of shunt function
N. Takeda, A. Inoue, Y. tbuchl, M. Tomikawa, M. Shirahata, T. Suqal, S. Sato. Dept. of Neurosurgery, Yamagata Prefectural CentralHospital, Yamagata, Japan Complete malfunctionof the cerebrospinal fluid (CSF) shunt is not so difficult to be diagnosed by CT scan, the shuntography using RI or contrast medium and clinical signs and symptoms. However, it is sometimesdifficult to diagnosethe incomplete malfunction of CSF shunt because of the gradualchanges in signs. symptomsandsize of the ventricle on CT scan especiallyin patientswith normal pressure hydrocephalus. To diagnose this incomplete malfunction of the shunt, the quantitative evaluation of the CSF dynamics in the ventricle is necessary. We evaluated the diagnostic value of the quantitative AI-ventriculography tor the incomplete malfunctionof the shunt. Methods: 111In-OTPA was administered into the ventricle via the flushing device of the shunt. The images and RI activities in the ventricles were taken and measured at O. 1, 6. 24. and 48 hours after the administration by the gamma camera. Patients do not need to be in bed during the examination period. The RI activities were corrected by a half-life of "'In (2.81 days) and the relative values at each time to that of I ' hour were calculated. Five patients with normal functioning shunt and five patients with incompletemalfunctioning shunt were studied. All cases have received ventriculo-peritoneal shunts after the subarachnoid hemorrhage. Time-value curves were drawn in each patient. ReSUlts: In normal functioning cases, mean relative values are 1 h:l.00 (control). 6 h:0.36 ± 0.09 (SO). 24 h:O.ll ± 0.08, and 48 h:O.04 ± 0.03 respectively. In incomplete malfunctioning cases, they were 1 h:1.00. 6 h:0.68 ± 0.12.24 h:0.52 ± 0.03. and 48 h:O.33 ± 0.12 respectively. There was a statistically significant difference (p < 0.001) between normal and malfunctioning groups (by repeated measures ANOVA). In the incomplete malfunctioning cases. time-valuecurves differedaccordingto the functioning levelof the shunt. The RI images were also useful to understandthe routes of CSF flow out of the ventricle. Conclusion: The quantitative RI-ventriculography using 1" ln-OTPA is a simpleand a useful methodto diagnose and estimate the incomplete malfunction of the shunt and/or CSF dynamics in the ventricle quantitatively.
IP.6.734' surgery: Epidural hematoma after ventriculoperitoneal shunt Report of 2 cases C.U. Pereira. W.T.Andrade. R.R. Holanda. M.W.S. Porto. Department of Neurosurgery, Funda9iioBeneficente Hospital De Cirurgia. Department of Neurosurgery, PedroI Hospital, FederalUniversity of Paraiba. Aracaju-se, Campina Grande-PB. Brazil Occurrence of epidural haematoma(EH) after ventriculoatrial or ventriculoperitoneal shuntoperations is a rarecondition. It may be a catastrophiccomplication of a relatively minor neurosurgicalprocedure. The authors report2 cases of EH after ventriculoperitoneal drainage. Case 01: A 33-year-old woman was admitted with the complaint of a persistent headache for the last 6 months. Neurological examination: Normal. CT: Moderate distended supratentorial ventricles and an intraventricular cystic lesion. Treatment: A medium pressure ventriculoperitoneal shunt was installed. Evolution: 4 months later the patient returned with severelthrobbing headache and dizziness. Neurological examination: Normal. CT: An encapsulated EH at the left posterior parietal region (corresponding the site of ventricularcatheter). Evolution: The patient did not accepled surgical treatment. Headachewas controlled by using analgesics. The patient is still asymptomaticnowadays. Case 02: A 39-year-old man came to the emergency service with the complaint of severe headache. vomits and fever. Neurological examination: Confused, nuchal rigidity and LCR revealed an inflammatory process. A highdosesof antibiotics were given intravenously. Evolution: The patient'sconditions markedly improved within 48 hs apart from persistent headache and bilateral papilledema. CT: Intracranial hypertension and an enlarged sella suggestiveof a craniopharyngioma. Treatment: VP Shunt has installed. Evolution: Somnolent and left hemiparesis no recovery CT: EH and right-ta-Ieft midline shift. Second treatment: EH was drained surgically. Evolution: He died shortlythereafter. We discuss aetiology.diagnosis and managementof EH afterventriculoperitoneal shunt surgery and pay particular attention to the treatment of hydracephalus with raised intracranial pressure.
IP-6-735! mechanism Spontaneous ventriculocisternostomy: A possible of arrested hydrocephalus W. Koszewski. Departmentof Neurosurgery, MedicalAcademy, WalSaw. Poland Introduction: Arrested hydrocephalus remains a condition not yet clearly understood in the aspect of underlying mechanism. The need for treatment in
Last Minute
5263
these cases is still a matter of discussion. The aim of the study was to define the pressure/volume characteristicof the condition and to evaluate the need for treatment. Methods: 4 adult patients presenting with enlarged ventricles on MRI and clinical symptoms suggesting arrested hydrocephalus were studied. Infusion test and long term ICP monitoring were performed to define the pressure volume characteristic and compensatory abilities of the intracranial space, thus to assess the need for treatment. Results: In all patients studied, MRI revealed ventriculomegaly associated with subcriticalaquaductalstenosis (aquaduct still being patent) and a spontaneouscommunication betweenthe floor of the third ventricle and the interpeduncular cistern (documented by fluid void signal). Pressure/volume studies have shown ICP (baseline resting pressure) to be within normal limits, however on the upper border (mean ICP level 10 mm Hg). No disturbances to CSF outflow have been documented(mean Resistance to CSF outflow 8 mmHglmllmin). No need lor shunt placement was established in the cases studied. Conclusions: The results suggest that subcritical aquaductal stenosis may be the necessary initial factor leading to a slight. long term elevation of intraventricular pressure and ventriculomegaly. This may result in spontaneous compensation by meansof ventriculocisternostomy - the mechanism responsible for the clinical condition termed arrested hydrocephalus.
IP-6-736! Absolute Meningitis or leptomeningeal carcinomatosis: contraindication for 3rd ventriculostomy? Uwe Kehler, Jan Gliemroth,Hans Arnold. Neurosurgical Department, Medical University of LUbeck. LUbeck, Germany Introduction: 3rd ventriculostomy is an established method lor treating noncommunicating hydrocephalus. The difficulty with regard to its indication is a reliable prediction of CSF absorption capacity. In meningitis or leptomeningeal carcinomatosis it is presumed that CSF absorption is impaired and, consequently. in concomitant noncommunicating hydrocephalus 3rd ventriculostomy is contraindicated. Nevertheless, we succeeded in 2 patients who had also aqueductal stenosis. Methods: Two patients presented with noncommunicating hydrocephalus and probably impaired CSF absorption, the first one with leptomeningeal carcinomatosis from non-Hodgkin lymphomaand an additional aqueductal obstruction, the other with Usteria meningitis and a triventricular hydrocephalUS without cleardemonstration of an aqueductalobstruction (during surgery a fibrin clot was found in the aqueduct). In both patients a 3rd ventriculostomy was performed, in the first patient an Ommaya reservoir for intraventricular chemotherapy was implanted as well. Results: Both patients. who preoperatively showed distinct signs of elevated ICP. recovered very well withinseveraldays. The MRls showeda slight decrease of ventricularsize. Conclusion: Even though in meningitis and leptomeningeal carcinomatosis CSF absorption may be impaired, this is not a rule without exception.Therefore, in additional noncommunicating hydrocephalus a 3rd ventriculostomy might be successful and patients should not be excluded from the beginning. The two cases showed that meningitis or leptomeningeal carcinomatosis is not an absolute contraindication for 3rd ventriculostomy.
Thursday, 10 July 1997
14:00-16:15
P-6 Last Minute
I P-6-737I
Brainstem and upper cervical tumor resection in a child: Advantages of surgical resection vs RT
E. Benericetti, E. Glornbelli, L. Macinante, E. Cosenza. C. Mesiti. A. Cusin. Department of Neurosurgery, MorelliHospital, Sondelo, Italy The authors report the clinical case of a three-year child who had previously undergone subtotal removal of a brainstem pilocytic astrocytoma in another Hospital. Few months later the baby presented a recurrence of the lesion involving brainstem and upper cervical spinal cord. Reoperation was preferred to RT treatment suggestedby another medical center: surgical treatment led to a complete tumor resectionwith recovery of baby's clinical conditions. 3-year follow-up shows satisfactory neurological status while MR shows no evidence of recurrence.
IP·6-733I
The sequential changes of intraventricular l11In·DTPA for quantitative evaluation of shunt function
N. Takeda, A. Inoue, Y. tbuchl, M. Tomikawa, M. Shirahata, T. Suqal, S. Sato. Dept. of Neurosurgery, Yamagata Prefectural CentralHospital, Yamagata, Japan Complete malfunctionof the cerebrospinal fluid (CSF) shunt is not so difficult to be diagnosed by CT scan, the shuntography using RI or contrast medium and clinical signs and symptoms. However, it is sometimesdifficult to diagnosethe incomplete malfunction of CSF shunt because of the gradualchanges in signs. symptomsandsize of the ventricle on CT scan especiallyin patientswith normal pressure hydrocephalus. To diagnose this incomplete malfunction of the shunt, the quantitative evaluation of the CSF dynamics in the ventricle is necessary. We evaluated the diagnostic value of the quantitative AI-ventriculography tor the incomplete malfunctionof the shunt. Methods: 111In-OTPA was administered into the ventricle via the flushing device of the shunt. The images and RI activities in the ventricles were taken and measured at O. 1, 6. 24. and 48 hours after the administration by the gamma camera. Patients do not need to be in bed during the examination period. The RI activities were corrected by a half-life of "'In (2.81 days) and the relative values at each time to that of I ' hour were calculated. Five patients with normal functioning shunt and five patients with incompletemalfunctioning shunt were studied. All cases have received ventriculo-peritoneal shunts after the subarachnoid hemorrhage. Time-value curves were drawn in each patient. ReSUlts: In normal functioning cases, mean relative values are 1 h:l.00 (control). 6 h:0.36 ± 0.09 (SO). 24 h:O.ll ± 0.08, and 48 h:O.04 ± 0.03 respectively. In incomplete malfunctioning cases, they were 1 h:1.00. 6 h:0.68 ± 0.12.24 h:0.52 ± 0.03. and 48 h:O.33 ± 0.12 respectively. There was a statistically significant difference (p < 0.001) between normal and malfunctioning groups (by repeated measures ANOVA). In the incomplete malfunctioning cases. time-valuecurves differedaccordingto the functioning levelof the shunt. The RI images were also useful to understandthe routes of CSF flow out of the ventricle. Conclusion: The quantitative RI-ventriculography using 1" ln-OTPA is a simpleand a useful methodto diagnose and estimate the incomplete malfunction of the shunt and/or CSF dynamics in the ventricle quantitatively.
IP.6.734' surgery: Epidural hematoma after ventriculoperitoneal shunt Report of 2 cases C.U. Pereira. W.T.Andrade. R.R. Holanda. M.W.S. Porto. Department of Neurosurgery, Funda9iioBeneficente Hospital De Cirurgia. Department of Neurosurgery, PedroI Hospital, FederalUniversity of Paraiba. Aracaju-se, Campina Grande-PB. Brazil Occurrence of epidural haematoma(EH) after ventriculoatrial or ventriculoperitoneal shuntoperations is a rarecondition. It may be a catastrophiccomplication of a relatively minor neurosurgicalprocedure. The authors report2 cases of EH after ventriculoperitoneal drainage. Case 01: A 33-year-old woman was admitted with the complaint of a persistent headache for the last 6 months. Neurological examination: Normal. CT: Moderate distended supratentorial ventricles and an intraventricular cystic lesion. Treatment: A medium pressure ventriculoperitoneal shunt was installed. Evolution: 4 months later the patient returned with severelthrobbing headache and dizziness. Neurological examination: Normal. CT: An encapsulated EH at the left posterior parietal region (corresponding the site of ventricularcatheter). Evolution: The patient did not accepled surgical treatment. Headachewas controlled by using analgesics. The patient is still asymptomaticnowadays. Case 02: A 39-year-old man came to the emergency service with the complaint of severe headache. vomits and fever. Neurological examination: Confused, nuchal rigidity and LCR revealed an inflammatory process. A highdosesof antibiotics were given intravenously. Evolution: The patient'sconditions markedly improved within 48 hs apart from persistent headache and bilateral papilledema. CT: Intracranial hypertension and an enlarged sella suggestiveof a craniopharyngioma. Treatment: VP Shunt has installed. Evolution: Somnolent and left hemiparesis no recovery CT: EH and right-ta-Ieft midline shift. Second treatment: EH was drained surgically. Evolution: He died shortlythereafter. We discuss aetiology.diagnosis and managementof EH afterventriculoperitoneal shunt surgery and pay particular attention to the treatment of hydracephalus with raised intracranial pressure.
IP-6-735! mechanism Spontaneous ventriculocisternostomy: A possible of arrested hydrocephalus W. Koszewski. Departmentof Neurosurgery, MedicalAcademy, WalSaw. Poland Introduction: Arrested hydrocephalus remains a condition not yet clearly understood in the aspect of underlying mechanism. The need for treatment in
Last Minute
5263
these cases is still a matter of discussion. The aim of the study was to define the pressure/volume characteristicof the condition and to evaluate the need for treatment. Methods: 4 adult patients presenting with enlarged ventricles on MRI and clinical symptoms suggesting arrested hydrocephalus were studied. Infusion test and long term ICP monitoring were performed to define the pressure volume characteristic and compensatory abilities of the intracranial space, thus to assess the need for treatment. Results: In all patients studied, MRI revealed ventriculomegaly associated with subcriticalaquaductalstenosis (aquaduct still being patent) and a spontaneouscommunication betweenthe floor of the third ventricle and the interpeduncular cistern (documented by fluid void signal). Pressure/volume studies have shown ICP (baseline resting pressure) to be within normal limits, however on the upper border (mean ICP level 10 mm Hg). No disturbances to CSF outflow have been documented(mean Resistance to CSF outflow 8 mmHglmllmin). No need lor shunt placement was established in the cases studied. Conclusions: The results suggest that subcritical aquaductal stenosis may be the necessary initial factor leading to a slight. long term elevation of intraventricular pressure and ventriculomegaly. This may result in spontaneous compensation by meansof ventriculocisternostomy - the mechanism responsible for the clinical condition termed arrested hydrocephalus.
IP-6-736! Absolute Meningitis or leptomeningeal carcinomatosis: contraindication for 3rd ventriculostomy? Uwe Kehler, Jan Gliemroth,Hans Arnold. Neurosurgical Department, Medical University of LUbeck. LUbeck, Germany Introduction: 3rd ventriculostomy is an established method lor treating noncommunicating hydrocephalus. The difficulty with regard to its indication is a reliable prediction of CSF absorption capacity. In meningitis or leptomeningeal carcinomatosis it is presumed that CSF absorption is impaired and, consequently. in concomitant noncommunicating hydrocephalus 3rd ventriculostomy is contraindicated. Nevertheless, we succeeded in 2 patients who had also aqueductal stenosis. Methods: Two patients presented with noncommunicating hydrocephalus and probably impaired CSF absorption, the first one with leptomeningeal carcinomatosis from non-Hodgkin lymphomaand an additional aqueductal obstruction, the other with Usteria meningitis and a triventricular hydrocephalUS without cleardemonstration of an aqueductalobstruction (during surgery a fibrin clot was found in the aqueduct). In both patients a 3rd ventriculostomy was performed, in the first patient an Ommaya reservoir for intraventricular chemotherapy was implanted as well. Results: Both patients. who preoperatively showed distinct signs of elevated ICP. recovered very well withinseveraldays. The MRls showeda slight decrease of ventricularsize. Conclusion: Even though in meningitis and leptomeningeal carcinomatosis CSF absorption may be impaired, this is not a rule without exception.Therefore, in additional noncommunicating hydrocephalus a 3rd ventriculostomy might be successful and patients should not be excluded from the beginning. The two cases showed that meningitis or leptomeningeal carcinomatosis is not an absolute contraindication for 3rd ventriculostomy.
Thursday, 10 July 1997
14:00-16:15
P-6 Last Minute
I P-6-737I
Brainstem and upper cervical tumor resection in a child: Advantages of surgical resection vs RT
E. Benericetti, E. Glornbelli, L. Macinante, E. Cosenza. C. Mesiti. A. Cusin. Department of Neurosurgery, MorelliHospital, Sondelo, Italy The authors report the clinical case of a three-year child who had previously undergone subtotal removal of a brainstem pilocytic astrocytoma in another Hospital. Few months later the baby presented a recurrence of the lesion involving brainstem and upper cervical spinal cord. Reoperation was preferred to RT treatment suggestedby another medical center: surgical treatment led to a complete tumor resectionwith recovery of baby's clinical conditions. 3-year follow-up shows satisfactory neurological status while MR shows no evidence of recurrence.