Hydrocephalus in children Eva Brichtova, M.D., Ph.D. Associate Professor FDN1 Ventricle system Ventricel system Ventricle system, cerebral cisterns Ventr 2 Ventr 3 Hydrocephalus taxonomy n- hypersecretion n- hyporesorbtion - n- obstructive (non-communicating) n- communicating (non-obstructive) - congenital - acquired - posthaemorrhagic - postinfekctious - posttraumatic - internal - external - - - - - active - arrested Signs and symptoms §Makrocephaly, fontanelle bulging, „setting sun sign“, Parinaud sy § §Intracranial hypertension n n cephalea - diffuse, valve headache, reverse Tinnel´s sign n vomitus - explosive, no nausea n vertigo n seazures n unconsciousness n respiratory and cardiac arrhytmia DSCN2340 Hydrocephalus Diagnosis of hydrocephalus §Neurology examination § §Neuroimaging modalities n - ultrasound n - CT n - MRI n §Ocular fundus Cerebral ultrasound examination Sono mozku Cerebral CT CT shunt MRI prubeh katetru Cerebral MRI Posthaemorrhagic hydrocephalus ultrasound imaging Sono hydrohemocefalus CT hydrohemocewfalus Posthaemorrhagic hydrocephalus CT imaging Hydrocephalus treatment nMedical nSurgery nMedicamentose (diuretics) n nSpinal tap n nVentricular punction n nVentricular drainage n nLumbar drainage Hydrocephalus treatment temporary Posthaemorrhagic hydrocephalus temporary treatment Port falzum Surgical treatment of hydrocephalus Drainage – shunting – VA, VP, (Nulsen, Spitz, Holter, Pudenz) Neuroendoskopy techniques A) Eliminating of obstruction cause (e.g. tumor exstirpation) B) Arteficial CSF communication (neuroendoskopy, Stoockey – Scarff) C) CSF drainage Surgical treatment of hydrocephalus Drainage nMost common surgery performed nCommunication between the ventricles and CSF resorbtion space Drainage modifications nventriculo – peritoneal VP n n nventriculo – atrial VA n n nlumbo - peritoneal Obr_11 Obr_10 Obr_12 nventriculo - subgaleal n n nventriculo - pleural n n nTorkildsen n n n Obr_9 Drainage modifications V-P drainage ventricular catheter valve peritoneal catheter Insertion of ventricular catheter Obr_4 Obr_7a Obr_8a Parieto-occipital Dorso-frontal Valves – non programmable Valve opening pressure: low pressure 50 mm H2O middle pressure 100 mm H2O high pressure 150 mm H2O neprogramovatelné shunty Programmable valves Obr_22 system Codman Programator Codman Obr_21 Programator strata Strata system Strata Medtronic Programmable valves Surgery - drainage VP shunt patient positioning Obr_28 Obr_29 Surgery - drainage - VP shunt Obr_30 Surgery - drainage - VP shunt Obr_31 Surgery - drainage - VP shunt Obr_32 Surgery - drainage - VP shunt Obr_34 Surgery - drainage - VP shunt Shunt malfunction § Neurological examination § § Fundus oculi § § Percutanneous valve test § § Velve pressure resetting (programable valves only) X-rays (systém Codman valve markers) Laterogram kapsle I Laterigram kaplse II § FW, blood count, inflammation markers, serum osmolarity § § CSF examination – valve punction (bakcteriology, biochemistry, cytology) § Laboratory examinations: Průbeh shuntu hlava Prubeh shuntu hlava II X-rays: Krátký katetr pro rust X-rays: Sono mozku Ultrasound: ct 00001 Centralni katetr - malfunkce CT MRI prubeh katetru MRI (cave programmable valves) Obturace centr katetru Central (ventricular) catheter malfunction - blood clot obturation Centralni katetr - obturace Central (ventricular) catheter malfunction chorioideal plexus adhesions Centralni katetr - malfunkce Central (ventricular) catheter malfunction malposition Operace ventrik katetru Central (ventricular) catheter malfunction Surgical treatment – catheter repositioning or replacement Obturace ventilu koagulem Slit ventricle CT Valve malfunction: § blood clot obturation § § elevated CSF viscosity (inflammatory process) § § slit ventricle syndrom § § Unsufficient catheter lenght due to pts growth (X – rays) § Distal catheter malfunction causes: § continuity cut-off § peritoneal adhesion § peritoneal pseudocyst - septic - aseptic § peritonitis due APE § hyporesorbtion – ascites § catheter intolerance, catheter expulsion § displacement to subcutaneous tissue § intestine perforation § hernia inguinalis, umbilicalis § Atrial catheter malfunction causes: § catheter thrombus (heart ultrasound) Distal catheter malfunction: Atriální katetr Krátký katetr pro rust Unsufficient catheter lenght due to pts growth Prerušení shuntu P katetru Prerusení shuntu bricho Continuity cut-off: - diconnection - disruption Operace výmena perit katetru Treatment – immediate surgery - re-connection if possible - catheter replacement (removing the displaced one) Peritoneal catheter – distal end - pseudocyst Sono1 Sono2 Septic: elevated CRP, FW, leukocytosis Ultrasound: Ucpaný P katetr2a Peritoneal adhesions Localized – laparoskopy, catheter deliberation, replacement Difffuse – temporary external drainage Intraluminal – catheter replacement Laparoskopy 3D, system Viking IMG_0971c Zevní drenáž I Zevní drenáž II § drainage extraction § § temporary external drainage § § antibiotics Infectious complication: Neuroendoscopy 1923 Mixter - first 3rd ventriculostomy 80s - neuroendoskopy techniques (flexible endoskopy, assisted endoskopy) HistorieE Obr_37 Obr_38 Obr_36 Neuroendoskopy Neuroendoskopy: nExstirpatio and biopsy of intra or periventricular expansions n nCyst marsurpialisation n nAqueductoplasty n nThird ventriculostomy n n Indications for Nuroendoskopy: §Obstructive hydrocephalus §Ventricular catheter implantation or replacement §Ventricular (paraventricular) tumors §Arachnoideal cyst §Subdural space revision Neuroendoskopy – complications: • haemorrhagy • hyperthermia (aseptic) • pneumocephalus • periventricular tissue damage • CSF fistula • infection • SD haematoma