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Premium member Presentation Transcript HYDROCEPHALUS : HYDROCEPHALUS ABUBAKAR IBRAHIM UMAR NEUROSURGERY UNIT PRESENTATIONOUT LINE: OUT LINE INTRODUCTION EPIDEMIOLOGY RELEVANT ANATOMY/ PHYSIOLOGY CLASSIFICATION AETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION INVESTIGATION DIFFERENTIAL DIAGNOSES TREATMENT COMPLICATION OUT COME CONCLUSIONINTRODUCTION: INTRODUCTION Hydrocephalus is an abnormal enlargement of the ventricles due to an excessive accumulation of cerebrospinal fluid (CSF) and thinning of cerebral mantle resulting from a disturbance of CSF flow, absorption or, uncommonly secretionINTRODUCTION…: INTRODUCTION… It is a disabling condition to both patients and their relatives, can lead to lifelong disability Early treatment improve neurological deficit and prevent mortalityEPIDEMIOLOGY: EPIDEMIOLOGY 1 – 4 per 1000 live births Peak age in infancy and early childhood Incidence of acquired type not exactly known Normal pressure hydrocephalus generally occur above 60 yrsRELEVANT ANATOMY/PHYSILOGY: RELEVANT ANATOMY/PHYSILOGYCirculation : Circulation Most of the CSF is secreted by the choroid plexuses in the lateral, third and fourth ventricles The total CSF volume is c.150 ml, of which 125 ml is intracranial. The ventricles contain c.25 ml The remaining 100 ml is located in the cranial subarachnoid spaceCirculation …: Circulation … CSF is secreted actively by carbonic anhydrase dependent pathway at a rate of 0.35-0.40 ml per minute CSF is absorbed into the venous system through arachnoid villi associated with the major dural venous sinuses, predominantly the superior sagittal sinusCLASSIFICATION: CLASSIFICATION HIGH OR NORMAL PRESSURE CONGENITAL – ACQUIRED COMMUNICATING -NONCOMMUNICATING NONOBSTRUCTIVE-OBSTRUCTIVEAETIOLOGY: AETIOLOGY Increase formation of CSF Choroid plexus papillomaAETIOLOGY…: AETIOLOGY… Obstruction in ventricular system Congenital: aquiductal stenosis , stenosis of foramina Post infectious : ependimitis , ventriculitis Post traumatic : intra ventricular hemorrhage Neoplasia : glioma , ependymoma , pituitary tumourAETIOLOGY…: AETIOLOGY… Obstruction in the sub arachnoid space Congenital Arnold chiari malformation Acquired Post infectious Post traumatic: sub arachnoid hemorrhage Neoplasm: subtentorial neoplasm, meduloblastomaAETIOLOGY…: AETIOLOGY… Impaired CSF absorption Congenital reduce number of arachnoid granulation, Acquired Post infectious Post hemorrhagic Neoplasms : parasagital menigiomas , mediastinal tumoursPATHOPHYSIOLOGY: PATHOPHYSIOLOGYPowerPoint Presentation: Accumulation of CSF Intraventricular hypertension Ventriculomegaly C/spinal, C/thalamic axons stretched, compressed. Demyelination Cerebral mantle stretched/thinned Centrum ovale , basal ganglia, thalamus - compressed Flattening of gyri Stretching of vasculature Thinning of septum pellucidum Erosion of vault and base of skull Subarachnoid spaces and cisterns dilate Subependymal necrosis and oedema Intraventricular haemorrhageCLINICAL PRESENTATION: CLINICAL PRESENTATION Age Underlying cause Rate of accumulation of CSFCLINICAL PRESENTATION…: CLINICAL PRESENTATION… Infants Enlargement of the head, crack pot sign Bulging fontanel Defective upward gaze Vomiting, Somnolence Irritability, Anorexia, Lethargy Hypertonia , hypereflxia , bradycardia , apnoeaCLINICAL PRESENTATION…: CLINICAL PRESENTATION… Older children and adults Headache Vomiting Nausea Blurred or double vision Impaired balance, coordination or gait Sluggishness or lack of energy Slowing or regression of development Memory lossCLINICAL PRESENTATION…: CLINICAL PRESENTATION… Older adults Syndrome of normal-pressure hydrocephalus Mild behavioral changes, forgetfulness, and apathy. Chronic hydrocephalus in the adult is characterized by dementia, urinary incontinence, and a gait disturbanceINVESTIGATIONS: INVESTIGATIONS Ultrasound scan Plain skull xray CT Scan MRIDIFFERENTIAL DIAGNOSES: DIFFERENTIAL DIAGNOSES Hydreencephaly Hydrocephalus ex vacou Subdural hematoma Scalp oedema PorencephalyTREATMENT: TREATMENT The goal is to achieve optimum neurological function, prevent or reverse the neurological symptoms. The best predictor is post opreative reconstitution of cerebral mantle to atleast 2.8 cm, this is likely if shunt occur by 5 month of age. Need for treatment: up to 45% may arrestTREATMENT…: TREATMENT… Medical Decrease CSF production : Acetozolamide , frusemide Increase CSF absorption: Heparin, Urokinase , Hyaluronidase Decrease Intracranial Pressure: Mannitol,Urea , GlycerolTREATMENT…: TREATMENT… Surgical Direct approach : choroid plexectomy , ventriculostomy Indirect approach Temporary : external ventricular drainage, lumbar drainage Permanent: ventricular shuntingTREATMENT…: TREATMENT… Types Ventriculo peritoneal Ventriculo venous/ atrial Ventriculo pleural Ventriculo cisternal /cervical Others: ureter , bladder, gall bladdder Lumbar peritoneal shunt Proximal catheter: frontal-occipitalVP Shunt: VP Shunt silicone ventricular catheter one-way valve distal silicone catheter. Other devices such as on/off valves, antisiphon devices, and flushing chambers.COMPLICATIONS: COMPLICATIONS Shunt system failure 70% in 10 years Mechanical failure Infection and Functional failure (under or over drainage)Mechanical failure : Mechanical failure Obstruction of ventricular catheter by choroid plexus, glial tissue, connective tissue, ependyma or brain tissue Fracture at sites of connectors Distal obstruction due to peritoneal pseudocyst , infectionMechanical failure …: Mechanical failure … Presentation worsening of symptoms Pumping may show site of obstruction Serial CT scan and shunt series confirm the diagnosis Treatment is by revision surgeryInfection : Infection Shunt infection occur in 2-8% 70% are diagnosed in the 1 st month and 90% by 6 month Common organisms are staph epidermidis , aureus , pneumococci Shunt tap for microbiological analysis Removal of shunt, external ventricular drainage and antibiotics should be givenFunctional failure : Functional failure Under drainage persistence of symptoms Over drainage may lead to subdural hematoma, low ICP syndrome, slit ventricle syndrome Prevention is by use of antisiphonOUT COME/ PROGNOSIS: OUT COME/ PROGNOSIS The natural history of untreated hydrocephalus is poor 50% dying before 3yrs, only 20-23% reach adult life, Only 38% of the survivors had normal intelligenceOUT COME/ PROGNOSIS…: OUT COME/ PROGNOSIS… Many patients with shunted hydrocephalus have normal intelligence and participate in all aspects of life 50-55% achieve IQ of >80 Epilepsy is a poor predictor of intelligenceCONCLUSION: CONCLUSION Despite advances in the management of hydrocephalus, the disease continue to cripple many children in developing countries due to late presentation, poverty and lack of resourcesREFERRENCES: REFERRENCES Principle and practice of surgery in the tropics Oxford textbook of surgery Essential neurosurgery Gray’s anatomy Pediatric surgery by J Grossfield Seminar presentation by Patrick OTHANK YOU: THANK YOU You do not have the permission to view this presentation. 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