HYDROCEPHALUS

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HYDROCEPHALUS :

HYDROCEPHALUS ABUBAKAR IBRAHIM UMAR NEUROSURGERY UNIT PRESENTATION

OUT LINE:

OUT LINE INTRODUCTION EPIDEMIOLOGY RELEVANT ANATOMY/ PHYSIOLOGY CLASSIFICATION AETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION INVESTIGATION DIFFERENTIAL DIAGNOSES TREATMENT COMPLICATION OUT COME CONCLUSION

INTRODUCTION:

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 secretion

INTRODUCTION…:

INTRODUCTION… It is a disabling condition to both patients and their relatives, can lead to lifelong disability Early treatment improve neurological deficit and prevent mortality

EPIDEMIOLOGY:

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 yrs

RELEVANT ANATOMY/PHYSILOGY:

RELEVANT ANATOMY/PHYSILOGY

Circulation :

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 space

Circulation …:

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 sinus

CLASSIFICATION:

CLASSIFICATION HIGH OR NORMAL PRESSURE CONGENITAL – ACQUIRED COMMUNICATING -NONCOMMUNICATING NONOBSTRUCTIVE-OBSTRUCTIVE

AETIOLOGY:

AETIOLOGY Increase formation of CSF Choroid plexus papilloma

AETIOLOGY…:

AETIOLOGY… Obstruction in ventricular system Congenital: aquiductal stenosis , stenosis of foramina Post infectious : ependimitis , ventriculitis Post traumatic : intra ventricular hemorrhage Neoplasia : glioma , ependymoma , pituitary tumour

AETIOLOGY…:

AETIOLOGY… Obstruction in the sub arachnoid space Congenital Arnold chiari malformation Acquired Post infectious Post traumatic: sub arachnoid hemorrhage Neoplasm: subtentorial neoplasm, meduloblastoma

AETIOLOGY…:

AETIOLOGY… Impaired CSF absorption Congenital reduce number of arachnoid granulation, Acquired Post infectious Post hemorrhagic Neoplasms : parasagital menigiomas , mediastinal tumours

PATHOPHYSIOLOGY:

PATHOPHYSIOLOGY

PowerPoint 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 haemorrhage

CLINICAL PRESENTATION:

CLINICAL PRESENTATION Age Underlying cause Rate of accumulation of CSF

CLINICAL PRESENTATION…:

CLINICAL PRESENTATION… Infants Enlargement of the head, crack pot sign Bulging fontanel Defective upward gaze Vomiting, Somnolence Irritability, Anorexia, Lethargy Hypertonia , hypereflxia , bradycardia , apnoea

CLINICAL 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 loss

CLINICAL 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 disturbance

INVESTIGATIONS:

INVESTIGATIONS Ultrasound scan Plain skull xray CT Scan MRI

DIFFERENTIAL DIAGNOSES:

DIFFERENTIAL DIAGNOSES Hydreencephaly Hydrocephalus ex vacou Subdural hematoma Scalp oedema Porencephaly

TREATMENT:

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 arrest

TREATMENT…:

TREATMENT… Medical Decrease CSF production : Acetozolamide , frusemide Increase CSF absorption: Heparin, Urokinase , Hyaluronidase Decrease Intracranial Pressure: Mannitol,Urea , Glycerol

TREATMENT…:

TREATMENT… Surgical Direct approach : choroid plexectomy , ventriculostomy Indirect approach Temporary : external ventricular drainage, lumbar drainage Permanent: ventricular shunting

TREATMENT…:

TREATMENT… Types Ventriculo peritoneal Ventriculo venous/ atrial Ventriculo pleural Ventriculo cisternal /cervical Others: ureter , bladder, gall bladdder Lumbar peritoneal shunt Proximal catheter: frontal-occipital

VP 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 , infection

Mechanical 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 surgery

Infection :

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 given

Functional 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 antisiphon

OUT 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 intelligence

OUT 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 intelligence

CONCLUSION:

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 resources

REFERRENCES:

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 O

THANK YOU:

THANK YOU