Degree Of Hydrocephalus Research Articles

Ventricular and parenchymal surface before and after shunting--do they have prognostic value for outcome?

26 consecutive patients with early hydrocephalus (median age at shunting 2.5 months) were followed up to the age of 3 years, prospectively. The work-up included: regular evaluation of psychomotor development and CT/MRI prior and 6 months following surgery. The latter with measurement of the area of the ventricles (degree of hydrocephalus) and the area of the hemispheres in cm(2) (area of hemispheres minus area of ventricles = parenchymal area and degree of brain mass) at the level of the slice with the largest area of the ventricles. 16 (62 %) had normal development (= Group A) and 10 (38 %) moderate or severe retardation (= Group B). The mean ventricular surface was 25.4 cm(2) in Group A and 31.2 cm(2) in Group B prior to surgery (p = 0.1) and 8.9 versus 14.1 cm(2) postsurgery (p = 0.2). The percentage decrease postoperatively was 59.9, versus 57.1 % (p = 0.4). The percentage of ventricular surface in relation to the hemispheres prior to surgery was 42.2 versus 51.4 % (p = 0.1) and post-surgery 12.8 versus 22.4 % (p = 0.1). The mean parenchymal surface was 34.9 cm(2) in Group A and 29.0 cm(2) in Group B prior to surgery (p = 0.3) and 60.9 versus 48.1 cm(2) post surgery (p = 0.07). Percentage increase was 87.3 % versus 77.3 % (p = 0.9). The absolute increase was 26.0 versus 19.0 cm(2) postoperatively (p = 0.2). In contrast to these mean values and their distribution with no significant differences in Group A and B there was some correlation between development and percentage of ventricular surface in relation to the hemispheres prior to surgery: more than 40 % is a critical value, because most of the later retarded children belonged to this radiological subgroup and only half of the later normal patients. After surgery, there was a distinct correlation between developmental outcome and parenchymal surface and its absolute increase in cm(2): most of those who had a normal outcome had a parenchymal surface of more than 40 cm(2) in the third trimenon and an increase of 20 cm(2) and more within six months post surgery, whereas this was the case in only 40 - 50 % of the retarded patients. In most young infants with hydrocephalus there is more brain mass than the ventricular enlargement suggests. The prognostic value of quantitative evaluation of neuroimaging should not be overestimated. Nevertheless, some prognostication in this age group is possible prior to surgery by measurement of ventricular area in relation to the hemispheres and after surgery by measurement of the parenchymal area and its increase in cm(2).

Idiopathic normal pressure hydrocephalus: a systematic review of diagnosis and outcome.

Patient selection for cerebrospinal fluid diversion is difficult, because idiopathic normal pressure hydrocephalus (INPH) mimics other neurodegenerative disorders and no findings reliably predict outcome. The literature was reviewed to identify diagnostic criteria that predict shunt response and to formulate prognostic expectations. MEDLINE was searched, and 44 articles meeting predetermined criteria were included. Clinical series were frequently retrospective with small patient numbers and unstandardized outcome evaluation. Clinical findings suggestive of shunt responsiveness were the complete triad (gait disturbance, urinary incontinence, and dementia) with early gait disturbance. Degree of hydrocephalus was not correlated with clinical improvement. Reduction of the subcortical low-blood flow area was correlated with improvement in three small studies. Clinical response to prolonged cerebrospinal fluid drainage predicted shunt outcome in all cases in two small series. Overall, 59% (range, 24-100%) of patients improved after shunting, and 29% (range, 10-100%) of patients experienced prolonged improvement. Complications occurred in 38% (range, 5-100%) of patients, additional surgery was required in 22% (range, 0-47%) of patients, and there was a 6% (range, 0-35%) combined rate of permanent neurological deficit and death. Shunting INPH is associated with an approximately 29% rate of significant improvement and a 6% significant complication rate. Enlargement of the subcortical low-flow area and clinical improvement secondary to prolonged lumbar drainage may provide additive predictive value above clinical and computed tomographic criteria. A multicenter clinical trial that focuses on the value of ancillary tests, defines the clinical course of a patient with a ventriculoperitoneal shunt, and evaluates the cost effectiveness of shunting INPH is needed to better describe outcome from shunting in INPH.

Prognostic factors for medulloblastoma

Purpose: To evaluate prognostic factors for medulloblastoma. Methods and Materials: One hundred and seventy-three consecutive patients with medulloblastoma, treated at King Faisal Specialist Hospital (KFSH) from 1988–1997, were reviewed. Eighty-four percent were children less than 15 years old. From 1988–1994, treatment was at the discretion of the investigator. From 1994–1998, patients entered a single-arm best practice protocol in which, in staged patients, the surgical intent was total resection, standard radiation treatment was defined, and adjuvant chemotherapy was given to a “high-risk” subset. Results: For 150 patients who completed surgical and radiation treatment, the 5-year survival rate was 58%, compared with 0% for 16 patients who were unable to start or complete radiation treatment. For staged patients, the 5-year survival was M0 + M1, 78% and M2 + M3, 21% ( p < 0.0001). Other favorable significant prognostic factors were age >14 years and gross cystic/necrotic features in the primary tumor. The size of the primary tumor, the degree of hydrocephalus at diagnosis, the presence of residual tumor in the post-operative CT/MRI, and the functional status of the patient prior to radiation treatment were not significant factors. Conclusions: Stage M0 + M1 was the most powerful favorable prognostic factor. In Saudi Arabia more patients present with advanced disseminated disease, 41% M2 + M3, than in the West, and this impacts adversely on overall survival. Total resection and standard radiation treatment were not sensitive prognostic factors in a treatment environment in which 78% of patients underwent at least 90% tumor resection and 60% received standard radiation treatment. In order to improve the proportion of patients able to complete radiation treatment, consideration should be given to limiting resection when the attainment of total resection is likely to be morbid, and to delaying rather than omitting radiation treatment in the patient severely compromised postoperatively.

Serial lumbar CSF presure measurements and cranial computed tomographic findings in childhood tuberculous meningitits.

Intracranial pressure (ICP) was monitored in 218 consecutive children with hydrocephalus secondary to tuberculous meningitis (TBM). All children underwent cranial computerized tomographic (CT) scanning and continuous lumbar cerebrospinal (CSF) pressure monitoring on admission. Noncommunicating hydrocephalus (37 children), as determined by air encephalography, was treated by ventriculoperitoneal (VP) shunting and communicating hydrocephalus (181 children), by means of daily acetazolamide and frusemide. Response of ICP to treatment in the group with communicating hydrocephalus was assessed by means of repeated CSF pressure monitoring and CT scanning. One hundred and eighty-five of the 218 patients survived the 1st month of treatment. The aim of this study was the retrospective determination of (1) the relationship between ICP measurements and CT findings on admission and (2) the characteristics of the ICP recording which correlated best with the CT criteria of compensated hydrocephalus after the 1st month of treatment. No relationship was found between the level of baseline CSF pressure and the degree of hydrocephalus, as demonstrated by CT scanning, on admission. Seventy-five per cent of the patients with communicating hydrocephalus that survived the 1st month of treatment complied with the CT criteria for compensated hydrocephalus. All these patients had a baseline CSF pressure below 15 mmHg and absence of high-amplitude B waves on the pressure recording done at the end of the 1st month. In this study repeated lumbar CSF pressure monitoring proved to be an effective instrument to assess the response of communicating tuberculous hydrocephalus to medical treatment and also accurately predicted the timing of compensation of the hydrocephalus.

A study of classification of spontaneous intraventricular haemorrhage: a report of 324 cases

In order to develop a practical classification of spontaneous intraventricular haemorrhage (IVH), a correlation was made between clinical and computed tomographic (CT) factors in 324 patients with IVH between September 1988 and December 1996. Spontaneous IVH was graded according to age, blood pressure, clinical conditions, conscious state on admission, primary site of bleeding, volume of intraparenchymal haematoma, degree of midline shift, degree of hydrocephalus and location of IVH, producing a score up to 20. A score of 0–5 was Grade I, 6–10 Grade II, 11–15 Grade III, 16–20 Grade IV. The mortality of each Grade, respectively, was 1.6%, 22.5%, 76% and 100%. The authors propose that this grading system may be a practical schema in the evaluation of the prognosis for IVH.

Intracranial subependymomas: CT and MR imaging features in 24 cases.

The intracranial subependymoma is a benign glioma that has been classically described as an asymptomatic fourth ventricular tumor found incidentally at autopsy in elderly men. The purpose of this study was to characterize the differences in CT and MR imaging appearances between subependymomas of the fourth and lateral ventricles, both of which were found in symptomatic patients. We retrospectively reviewed 24 pathologically proved cases of intracranial subependymomas in 17 male and seven female patients with a mean age of 48.1 years. All patients were symptomatic. CT and MR images were used to characterize the size, shape, and location of the subependymomas; the degree of hydrocephalus; tumor calcification; and the density, signal, and enhancement characteristics of the tumors. Eighteen of 24 tumors were 3 cm or more in greatest dimension. Nineteen were lobulated, and hydrocephalus was seen in 21. Fourteen were in the lateral ventricle, and 10 were in the posterior fossa. Calcifications were present in five (all fourth ventricular) and absent in 10 (all lateral ventricular) subependymomas imaged with unenhanced CT. On 18 contrast-enhanced CT scans, five of six subependymomas with heterogeneous enhancement were in the fourth ventricle, and nine of 12 tumors with minimal or no enhancement were in the lateral ventricle. Small internal foci with a signal intensity similar to that of CSF were seen on images of all 10 lateral ventricular subependymomas obtained with both T1-weighted and T2-weighted sequences. On 13 contrast-enhanced T1-weighted images, seven of eight tumors with heterogeneous enhancement were in the fourth ventricle, and all five with minimal or no enhancement were in the lateral ventricle. Intracranial subependymomas were seen in symptomatic middle-aged adults and showed different CT and MR imaging features, depending on their anatomic location. Calcification and heterogeneous contrast enhancement were common features of fourth ventricular subependymomas showed a lack of calcification as well as minimal or no contrast enhancement of CT and MR images.

Serial CT Scanning in Childhood Tuberculous Meningitis: Prognostic Features in 198 Cases

Serial cranial computed tomographic (CT) scanning and intracranial pressure monitoring were performed on 198 children with stage II and III tuberculous meningitis. The aims of the study were to document the course of tuberculous hydrocephalus during medical and surgical treatment, as well as the prognostic significance of parenchymal changes in the brain as demonstrated by CT. Lumbar cerebrospinal fluid pressure was monitored continuously for a 1-hour period in all patients on admission and at weekly intervals in patients with communicating hydrocephalus for the 1st month of treatment. Cranial CT scanning was done on admission and repeated in survivors after 1 month and again after 6 months of antituberculous therapy. The raised intracranial pressure of 112 children with communicating hydrocephalus, as demonstrated by air-encephalography, was treated medically (with daily acetazolamide and furosemide) for 1 month. Thirty-one children with noncommunicating hydrocephalus were referred for immediate ventriculoperitoneal shunting. No significant difference was found in the eventual ventricular size or clinical outcome between the two treatment groups. Lumbar cerebrospinal fluid pressure changes in the children with communicating hydrocephalus closely followed changes in the degree of hydrocephalus during the course of treatment. The main cause of permanent neurologic disability was basal ganglia infarction, which occurred unilaterally in 21% and bilaterally in 10% of patients on admission and developed in a further 22% of children during treatment. A prominent subarachnoid space, which was seen on the CT scan of 36% of patients after the 1st month of treatment and which reverted to normal, probably relates to the poor nutritional state of these patients on admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Whither preoperative shunts for posterior fossa tumours?

Some degree of hydrocephalus is present in almost all cases of medium to large posterior fossa tumours. The initial symptoms in such cases are usually due to the hydrocephalus and the consequent increased supratentorial pressure, and more often precede the symptoms primarily due to the local invasion and compression of the brain stem and cerebellum by a significant length of time. In our experience, based on 62 posterior fossa tumour operations, insertion of a cerebrospinal fluid (CSF) diverting shunt because of hydrocephalus makes the subsequent tumour excision more difficult and hazardous. The various problems presumed to be related to preoperative shunt surgery are discussed in this report. It is concluded that preoperative shunts for posterior fossa tumours are rarely indicated.

A behavior profile of the [formula omitted][formula omitted] mouse and its association with hydrocephalus

Since the NZB and BXSB autoimmune mouse strains have cortical ectopias and associated behavioral changes, mice from the MRL 1 ( MRL Mp lpr lpr ) autoimmune strain were given a series of behavioral tests followed by anatomical analyses of their brains and immune assays of plasma. No cortical ectopias were found, but this strain was discovered to have a high incidence of hydrocephalus: 46% had severe dilatation of the lateral and third ventricles, 30% had moderate dilatation, and 24% had minimal or no enlargement of the ventricles (total N = 57). Those mice in the severe hydrocephalus group were poorer in a nonspatial discrimination learning task, had less paw asymmetry, and were less active in a swimming task. No association was found between degree of hydrocephalus and any immune parameter.

Tuberculous Hydrocephalus: Comparison of Different Treatments With Regard to Icp, Ventricular Size and Clinical Outcome

The effect of different treatment regimes on intracranial pressure (ICP), degree of hydrocephalus and clinical outcome was evaluated in 81 children with tuberculous meningitis. 24 children underwent CSF shunting, while 57 with communicating hydrocephalus were randomly assigned to three treatment groups: antituberculous drugs only; or additional intrathecal hyaluronidase or oral acetazolamide and furosemide in addition to antituberculous treatment. The addition of acetazolamide and furosemide was significantly more effective in achieving normal ICP than antituberculous drugs alone. No difference was found in mortality or number of disabled survivors between groups. Of those surviving, nearly two-thirds with stage II tuberculous meningitis were mildly disabled and nearly one-half with stage III were severely disabled at follow-up, emphasising the need for early diagnosis of tuberculous meningitis in the young child.

Basilar impression in a child with hypochondroplasia

A 4-year-old boy with hypochondroplasia presented with delay in gross motor development. Magnetic resonance imaging demonstrated basilar impression with compression at the craniovertebral junction and mild degree of hydrocephalus. Posterior fossa decompression resulted in improvement in neurologic function and relief of hydrocephalus.

Tuberculous Meningitis

Tuberculous meningitis is an uncommon but potentially devastating form of tuberculosis. Current antituberculous drugs are highly effective when treatment is initiated early, before the onset of altered mentation or focal neurologic deficits. Because the clinical outcome depends greatly on the stage at which therapy is initiated, early recognition is of paramount importance. Patients with the meningoencephalitis syndrome and CSF findings of low glucose levels, elevated protein levels, and pleocytosis should be treated immediately if there is evidence of TB elsewhere in the body, or if prompt evaluation fails to establish an alternative diagnosis. Examination of CSF is the best diagnostic approach; with sufficient diligence, serial AFB smears and cultures will usually yield positive results, even days after therapy has been started. The CT scan is an important and highly effective tool for the diagnosis and management of patients with TBM. In a patient with compatible clinical features, the combination of basilar meningeal enhancement and any degree of hydrocephalus is strongly suggestive of the diagnosis of TBM. Serial evaluation by CT scanning is useful for following the course of hydrocephalus and tuberculoma, particularly in reference to the need for, or response to, adjunctive therapy with corticosteroids and surgery. The decision to administer corticosteroids should be based on careful correlation of the clinical and radiographic features of the case. Surgical shunting should be considered early in the patient with hydrocephalus and symptoms of raised intracranial pressure. Tuberculomas are best treated medically, often in conjunction with corticosteroids where cerebral edema is believed to contribute to neurologic decline. The recommended chemotherapy regimen is isoniazid and rifampin in all patients, together with pyrazinamide for the first 2 months.

The amount of blood in CSF and degree of hydrocephalus studied with CT as compared to clinical condition and concentrations of various substances in human CSF after subarachnoid haemorrhage

Thirty-nine (39) patients with subarachnoid haemorrhage (SAH) were studied with computed tomography (CT). The amount of blood in the cerebrospinal fluid (CSF) and the degree of hydrocephalus were evaluated. These two parameters were correlated with the clinical condition on admission and at discharge and against CSF concentration of a series of CSF substances. These included the major monoamine metabolites homovanillic acid (HVA), 5-hydroxyindole-acetic acid (5-HIAA) and 3-methoxy-4-hydroxyphenylethyleneglycol (MOPEG) and in addition the concentrations of hypoxanthine, aspartate and somatomedins. The amount of blood and the degree of hydrocephalus on admission did not seem to influence the concentration of these substances over time. It was found that patients with large amounts of blood in the CSF had a worse clinical outcome (p less than 0.05) compared to patients with no or moderate amount of blood. In addition, patients with enlargement of the temporal horns showed a worse clinical condition on admission (p less than 0.01) than did patients without such enlargement. Despite a significant (p less than 0.01) vasoconstriction there was no correlation between vascular calibre and concentration of the substances in the CSF. It is speculated whether or not the increased levels of these substances were the result of cell lysis per se, a disturbance of the CSF circulation or to the toxic effect of blood resulting in deranged metabolism in both the CSF and brain tissue after SAH.

Upper-limb function of children with myelomeningocele.

Upper-limb function of 33 children aged between four and 17 years, all with myelomeningocele and hydrocephalus, was investigated by clinical examination and formal tests of hand function. Cerebellar ataxia alone or with other neurological signs was the most common disorder detected. Hand-function scores were determined for each child and for different components of hand function, and the mean score for the whole group was only 59 per cent. In general, children over 11 years of age scored significantly better than younger ones. Children under 11 years of age with a milder degree of hydrocephalus or who were right-handed also scored significantly better. Only two children had clinically normal upper limbs.

The CSF pulse wave in hydrocephalus.

Twenty-one dogs were rendered hydrocephalic by the intracisternal injection of kaolin. After various intervals between 1 and 44 days the animals were anesthetized for the measurement of arterial (lingual), ventricular, and sagittal sinus pressures. Following the recordings the animals were sacrificed by formalin infusion, the brains sectioned serially, and ventricular size measured. In general, the longer the period of incubation the larger the ventricles. There was no correlation between the degree of hydrocephalus and mean or pulsatile ventricular pressure. All animals with a pressure of less than 9 torr demonstrated non-linear transmission of the arterial wave into the CSF (which is the same as the pulse in the venous bed). All animals with a pressure greater than 12 torr had linear transmission of the wave. These findings in the hydrocephalic animals are the same as those found in nonhydrocephalic animals with similar pressures. It is concluded that the CSF pulse wave seen in hydrocephalic dogs is a result of how the cerebrovascular bed processes the cardiac pulse wave and is independent of the hydrocephalic process. There is no evidence that the pulse wave produces hydrocephalus.

Intracranial pressure monitoring in tuberculous meningitis: clinical and computerized tomographic correlation.

Cerebrospinal fluid (CSF) pressure was monitored in 24 children with acute tuberculous meningitis. 19 had raised intracranial pressure (ICP) as reflected by increased baseline pressure, pressure waves (e.g. B-waves) and increased amplitude of the pulse wave. Correlation between clinical signs of raised ICP and monitored CSF pressure showed that clinical diagnosis of the presence and degree of raised ICP is unreliable, especially in children with a closed anterior fontanelle. Computerized tomographic (CT) scans showed that hydrocephalus was present in all children with raised CSF pressure. No direct correlation was found between the degree of hydrocephalus and the degree of raised ICP. The rôle of ICP monitoring in the diagnosis and management of raised ICP in children with tuberculous meningitis is discussed.

Intellectual sequelae of primary non-obstructive hydrocephalus in infancy: Analysis of 50 cases

In 50 cases of primary non-obstructive nonprogressive hydrocephalus in infancy, possibilities of predicting later intelligence were investigated. The mean IQ was 80 ± 24; in 50% of the cases IQ was normal, in 22% between 85 and 55 and in 28% below 55. The occipitofrontal circumference and the degree of ventricular enlargement had no correlation with the intellectual outcome in the children. Most prognostic value on the IQ had the age when reaching the developmental milestones, the degree of motor disability and the number of minor malformations. As there was no relation between the degree of hydrocephalus and the intellectual impairment, the conclusion can be made that associated anomalies of the CNS and defects in the cyto-architecture of the neocortex are more important factors in explaining mental retardation in cases of hydrocephalus.

Diagnosis of masses presenting within the ventricles on computed tomography.

The radiological and clinical features of 90 histologically verified intraventricular masses were reviewed. Computed tomography (CT) and plain X-rays were available in all and angiograms in over half the cases. The localisation, effects on the adjacent brain substance and the presence and degree of hydrocephalus was evident on CT. Two-thirds of colloid cysts presented as pathognomonic anterior third ventricular hyperdense masses and the other third were isodense; an alternative diagnosis should be considered for low density masses in this situation. Plexus papillomas and carcinomas mainly involved the trigone and body of a lateral ventricle of young children and caused asymmetrical hydrocephalus; the third ventricle was occasionally affected also in children and the fourth ventricle more frequently and usually in adults. Two-thirds were hyperdense, one-third of mixed or lower density. The meningiomas were dense trigonal tumours of adults generally arising in the choroid plexus, but two tentorial meningiomas passed through the choroidal fissure and caused a predominantly intraventricular mass. Gliomas frequently thickened the septum and generally involved the frontal segments of the lateral ventricles. They may be supplied by perforating as well as by the choroidal arteries, which supply most other vascularised masses within the ventricles. Only 10% of our cases did not fall into one of the former categories; these included low density non-enhancing dermoid or epidermoid tumours and higher density enhancing metastatic or angiomatous masses.

Tuberculous Meningitis.

Tuberculous meningitis is an uncommon but potentially devastating form of tuberculosis. Current antituberculous drugs are highly effective when treatment is initiated early, before the onset of altered mentation or focal neurologic deficits. Because the clinical outcome depends greatly on the stage at which therapy is initiated, early recognition is of paramount importance. Patients with the meningoencephalitis syndrome and CSF findings of low glucose levels, elevated protein levels, and pleocytosis should be treated immediately if there is evidence of TB elsewhere in the body, or if prompt evaluation fails to establish an alternative diagnosis. Examination of CSF is the best diagnostic approach; with sufficient diligence, serial AFB smears and cultures will usually yield positive results, even days after therapy has been started. The CT scan is an important and highly effective tool for the diagnosis and management of patients with TBM. In a patient with compatible clinical features, the combination of basilar meningeal enhancement and any degree of hydrocephalus is strongly suggestive of the diagnosis of TBM. Serial evaluation by CT scanning is useful for following the course of hydrocephalus and tuberculoma, particularly in reference to the need for, or response to, adjunctive therapy with corticosteroids and surgery. The decision to administer corticosteroids should be based on careful correlation of the clinical and radiographic features of the case. Surgical shunting should be considered early in the patient with hydrocephalus and symptoms of raised intracranial pressure. Tuberculomas are best treated medically, often in conjunction with corticosteroids where cerebral edema is believed to contribute to neurologic decline. The recommended chemotherapy regimen is isoniazid and rifampin in all patients, together with pyrazinamide for the first 2 months.

Ultrastructural observations in experimental hydrocephalus in the rabbit

Changes in the ependyma and periventricular brain tissues of the lateral, 3rd and 4th ventricles and the cervical spinal canal were studied electron-microscopically in young rabbits on the 9th day after injecting kaolin into the cisterna magna. The ependyma of the lateral ventricle overlying the white matter was notably stretched causing increased egress of CSF and disorganisation of the normal architecture of the white matter and capillaries. The neurons and glial cells close to the white matter showed edematous changes. The changes in the ependymal lining and the underlying grey matter were less severe in the dorsal part of the 3rd and the 4th ventricle. The ventral part of the 3rd ventricle was the least affected. The height and the arrangement of the ependymal cells, the surrounding grey matter with narrow interstitial spaces and the absorbing tanycytes seemed to be factors which were responsible for the minimal changes in these regions. The changes appeared to be reversible if the CSF pressure was relieved at this stage. The spinal canal remained unaffected in the majority of our hydrocephalic animals, which could probably be attributed to the type of animal and the degree of hydrocephalus.